What is the recommended splint for a comminuted fracture of the proximal phalanx of the big toe?

Recommended Splinting for Comminuted Fracture of the Proximal Phalanx of the Big Toe

For a comminuted fracture of the proximal phalanx of the big toe, immobilization using buddy taping to the adjacent toe combined with a rigid-sole shoe is the recommended splinting approach to limit joint movement while promoting proper healing. 1

Assessment and Initial Management

• Comminuted fractures of the proximal phalanx of the big toe typically result from crushing injuries, axial forces, or direct trauma 2
• Evaluate for signs of circulatory compromise (blue, purple, or pale appearance), which would require immediate emergency response 1
• Assess for open wounds associated with the fracture, which should be covered with a clean dressing to reduce risk of contamination and infection 1

Splinting Technique

• Buddy taping technique:

  • Clean and dry the affected toe and adjacent toe
  • Place thin padding (such as gauze or cotton) between the toes to prevent skin maceration
  • Secure the fractured toe to the adjacent toe using non-elastic tape 2
  • Ensure the tape is not too tight to avoid compromising circulation 1

• Rigid-sole shoe:

  • A post-operative or rigid-sole shoe should be used in conjunction with buddy taping to limit movement at the fracture site 2
  • This combination helps immobilize the toe while allowing weightbearing as tolerated 1

Indications for Referral

• Referral to an orthopedic specialist is indicated for any of the following conditions:
  • Circulatory compromise
  • Open fractures
  • Significant soft tissue injury
  • Fracture-dislocations
  • Displaced intra-articular fractures
  • Unstable fractures of the first toe
  • Fractures involving more than 25% of the joint surface 2

Treatment Duration and Follow-up

• The splint should remain in place for approximately 4-6 weeks, depending on fracture severity 2
• Follow-up radiographs should be obtained at 10-14 days to ensure proper alignment is maintained 1
• For pediatric patients with epiphyseal involvement, closer monitoring is required due to risk of growth disturbances 3

Special Considerations

• For highly comminuted or unstable fractures of the proximal phalanx, more advanced fixation methods may be required, but these would be implemented by a specialist after referral 4
• Avoid attempting to reduce displaced fractures without proper training, as this could worsen the injury 1
• Monitor for signs of compartment syndrome, which although rare in toe injuries, can occur with severe crushing mechanisms 2

Pitfalls to Avoid

• Overtightening the buddy tape, which can compromise circulation and cause tissue necrosis 1
• Inadequate padding between toes, which can lead to skin maceration and potential infection 2
• Premature removal of splinting before adequate healing has occurred 2
• Failure to recognize fractures requiring specialist intervention, particularly those involving the joint surface 2, 4