Is an X-ray (x-ray) of the foot necessary to diagnose a suspected broken toe?

X-ray for Suspected Broken Toe

Radiographs are appropriate and necessary to document or rule out a fracture when a toe fracture is suspected, as the Ottawa rules do not directly address injuries to the toes. 1

Diagnostic Approach for Suspected Toe Fractures

• The Ottawa rules for foot injuries primarily address midfoot injuries and do not specifically cover injuries to the toes or distal forefoot 1
• When a toe fracture is clinically suspected based on point tenderness or pain with gentle axial loading of the digit, radiographs should be obtained to confirm the diagnosis 1, 2
• Standard radiographic evaluation typically includes anteroposterior and oblique views to identify fractures, determine displacement, and evaluate adjacent phalanges 2
• X-rays provide documentation of fracture presence, location, and alignment, which guides appropriate treatment decisions 1

Clinical Considerations

• Most toe fractures result from crushing injuries or axial force trauma (such as stubbing the toe), with point tenderness at the fracture site being a common clinical finding 2
• While the Ottawa rules have 99% sensitivity for detecting foot fractures in the midfoot region, these rules specifically exclude the toes from their assessment criteria 1
• Radiographs are the mainstay of initial imaging for acute foot trauma, including toe injuries, with a typical three-view study being standard 1
• Ultrasound has shown less successful results compared to radiographic evaluation for foot fractures, with only 90.9% sensitivity and specificity 1

Treatment Based on Radiographic Findings

• Stable, nondisplaced toe fractures can be treated with buddy taping and a rigid-sole shoe to limit joint movement 2, 3
• Great toe (first toe) fractures typically require a short leg walking boot or cast with toe plate for 2-3 weeks, followed by a rigid-sole shoe for an additional 3-4 weeks 3
• Lesser toe fractures can be managed with buddy taping to an adjacent toe and a rigid-sole shoe for 4-6 weeks 3
• Displaced fractures of the first toe often require referral for reduction and stabilization, especially if they involve more than 25% of the joint surface 2

When to Refer

• Referral is indicated for patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, or displaced intra-articular fractures 2
• First toe fractures that are unstable or involve more than 25% of the joint surface generally require specialist consultation 2
• Most pediatric patients with fractures involving the growth plate (physis) should be referred, though selected nondisplaced Salter-Harris types I and II fractures may be managed by primary care physicians 2

Pitfalls and Caveats

• Failure to obtain radiographs for suspected toe fractures may lead to missed diagnoses and improper treatment 1
• Attempting manipulation of foot injuries before radiographic assessment may increase the risk of requiring re-manipulation (44% before X-ray vs. 18% after X-ray) 4
• While the Ottawa rules are highly sensitive for midfoot fractures, their application does not extend to toe injuries, creating a potential diagnostic gap if relied upon exclusively 1
• Buddy taping should be applied with appropriate tension to provide stability without compromising circulation 5