Treatment for Nondisplaced Intra-articular Proximal Phalanx Great Toe Fracture Not Healing
Surgical intervention with bone grafting and internal fixation is the recommended treatment for nonunion of a nondisplaced intra-articular proximal phalanx fracture of the great toe. 1
Initial Assessment
- Confirm nonunion status through radiographic studies and clinical examination, as nonunion of phalangeal fractures often presents with persistent pain and limited function 1
- Evaluate for risk factors that may have contributed to nonunion, such as inadequate initial immobilization, poor blood supply, or patient factors 2
- Assess the degree of displacement, which may have progressed from the initial nondisplaced state, as this will influence the surgical approach 3
Treatment Algorithm
First-line Treatment: Surgical Intervention
Autologous bone grafting with precise bone peg formation is highly effective for nonunion of proximal phalanx fractures of the great toe 1
- This technique provides both structural support and biological factors to promote healing
- The bone peg is precisely formed to fit the medullary cavity similar to an intramedullary nail
Internal fixation options based on fracture characteristics:
- For simple nonunion patterns: K-wire fixation may be sufficient 2
- For more complex nonunion: Screw fixation (particularly headless compression screws) provides rigid fixation while minimizing soft tissue irritation 3
- For comminuted nonunion: Plate fixation may be necessary to provide adequate stability 2
Alternative Approaches
- External fixation may be considered in cases with significant soft tissue compromise or infection 4
- External fixator systems can provide stability while allowing wound management
- This approach minimizes additional soft tissue disruption at the fracture site
Postoperative Management
- Protected weight-bearing for approximately 6-8 weeks to allow for bone healing 1
- Early range of motion exercises after adequate healing (typically 5-6 weeks post-surgery) to prevent stiffness 4
- Regular radiographic follow-up to monitor healing progress 1
Potential Complications and Management
Be aware of the high complication rate after surgical intervention for intra-articular fractures of the great toe 5
- Complications may include redisplacement, refracture, avascular necrosis, and posttraumatic arthritis
- Despite complications, most patients can achieve satisfactory functional outcomes with appropriate management 5
For persistent nonunion or development of posttraumatic arthritis after initial surgical intervention:
Special Considerations
- Minimize soft tissue dissection during surgery to preserve blood supply to the fracture fragments 3
- Ensure rigid fixation to allow for early range of motion and faster return to function 3
- Consider bone stimulation in cases with poor healing potential or after failed primary surgical intervention 2
While there is limited high-quality evidence specifically addressing nonunion of great toe proximal phalanx fractures, the principles of treating nonunion in other phalanges can be applied, with bone grafting and appropriate fixation being the cornerstone of management 1, 2.