What is the recommended initial management for a patient with severe osteoarthritis and a nondisplaced intra-articular fracture of the proximal phalanx of the great toe?

Management of Severe Osteoarthritis with Nondisplaced Intra-articular Fracture of Proximal Phalanx of Great Toe

Initial management should include immobilization, pain control with oral NSAIDs, and weight-bearing restrictions to promote healing while addressing the underlying osteoarthritis. 1

Initial Assessment and Management

• Immobilization with buddy taping and a rigid-sole shoe to limit joint movement is the primary treatment for stable, nondisplaced intra-articular fractures of the proximal phalanx 1
• Pain control should begin with oral NSAIDs at the lowest effective dose for the shortest possible duration 2
• Weight-bearing restrictions should be implemented to prevent displacement of the fracture and allow proper healing 1
• Acetaminophen can be used as an alternative or adjunct to NSAIDs for pain management in patients with contraindications to NSAIDs 2

Pharmacologic Management for Osteoarthritis

• Oral NSAIDs are conditionally recommended as first-line pharmacologic therapy for osteoarthritis, providing both analgesic and anti-inflammatory effects 2
• Tramadol may be considered if NSAIDs and acetaminophen provide inadequate pain relief 2
• Intra-articular corticosteroid injections should be delayed until fracture healing is complete but can be considered for persistent osteoarthritis pain after healing 2
• Avoid chondroitin sulfate and glucosamine as they are not recommended for osteoarthritis management 2

Non-Pharmacologic Management

• Once fracture healing begins, implement a supervised exercise program focusing on:
  • Cardiovascular and resistance land-based exercise 2
  • Aquatic exercise for reduced weight-bearing during rehabilitation 2
• Weight loss is strongly recommended for overweight patients with osteoarthritis 2
• Self-management programs and psychosocial interventions should be incorporated into the treatment plan 2
• Thermal agents (heat/cold) can be used as adjunctive therapy for pain relief 2

Monitoring and Follow-up

• Radiographic evaluation should be performed at 2-3 weeks to ensure proper alignment and healing 1
• Regular assessment of pain relief and functional improvement during treatment 1
• Monitor for complications such as displacement, nonunion, or post-traumatic arthritis 3

Indications for Referral to Orthopedic Surgery

• Development of displacement during treatment 1
• Signs of nonunion after appropriate conservative management 3
• Fracture involving more than 25% of the joint surface 1
• Development of post-traumatic arthritis with significant functional limitation 3
• Significant soft tissue injury or circulatory compromise 1

Potential Complications

• There is a high complication rate after surgical intervention for intra-articular fractures of the great toe, including nonunion, avascular necrosis, and post-traumatic arthritis 3
• Conservative management is preferred when possible, especially given the underlying osteoarthritis 3, 1
• Even with complications, most patients return to full activity without limitation with appropriate management 3

Special Considerations

• The presence of severe osteoarthritis may complicate fracture healing and influence long-term outcomes 2
• Patients with osteoarthritis should continue their osteoarthritis management concurrently with fracture treatment 2
• Older patients may require more aggressive pain management and longer healing times 1