What is the treatment for an oblique fracture through the shaft of the proximal phalanx of the fourth toe?

Treatment of Oblique Fracture Through the Shaft of the Proximal Phalanx of the Fourth Toe

Conservative management with buddy taping and appropriate footwear is the recommended first-line treatment for an oblique fracture through the shaft of the proximal phalanx of the fourth toe.

Diagnostic Assessment

• Standard radiographic examination should include at least 3 views:
  • Anteroposterior (AP)
  • Lateral
  • Oblique views
• An internally rotated oblique projection, in addition to the standard externally rotated oblique, increases diagnostic yield for phalangeal fractures 1

Treatment Algorithm

For Stable, Non-Displaced or Minimally Displaced Fractures

1. Conservative Management (First-Line)

   • Buddy taping to adjacent toe (typically the third or fifth toe)
   • Wide-toe box, stiff-soled shoes or post-operative shoe to reduce motion
   • Weight-bearing as tolerated
   • Ice and elevation to reduce swelling
   • Appropriate analgesics for pain control

2. Expected Healing Time

   • Clinical and radiographic healing typically occurs within 4-6 weeks
   • Full return to activities usually at 6-8 weeks

For Unstable or Significantly Displaced Fractures

1. Criteria for Surgical Intervention

   • Displacement >2mm
   • Angulation >10 degrees
   • Rotational deformity
   • Intra-articular extension
   • Open fractures

2. Surgical Options

   • Closed reduction and percutaneous Kirschner wire fixation
   • For comminuted fractures or those with poor bone quality, mini-fragment screws or plates may be considered 2

Rationale for Treatment Approach

The conservative approach is preferred for most toe phalangeal fractures because:

• The fourth toe is non-weight-bearing and has limited functional demands
• Most oblique fractures of the proximal phalanx heal well with conservative management
• Surgical intervention carries risks of infection, hardware complications, and prolonged recovery

Monitoring and Follow-up

• Clinical assessment at 1-2 weeks to ensure proper alignment
• Radiographic evaluation at 4-6 weeks to confirm healing
• Buddy taping can be discontinued once clinical healing is evident (usually 4-6 weeks)

Potential Complications

• Malunion (typically well-tolerated in the fourth toe)
• Delayed union
• Stiffness of the toe joints
• Chronic pain

Special Considerations

• For patients with diabetes or peripheral vascular disease, more frequent monitoring is recommended due to increased risk of complications
• In patients with osteoporosis, longer immobilization may be necessary for adequate healing
• For athletes or patients with high physical demands, a more aggressive approach to ensure anatomic alignment may be warranted

The functional outcome for oblique fractures of the proximal phalanx of the fourth toe is generally excellent with appropriate management, with most patients returning to full activities without limitations.