Can a nondisplaced intra-articular fracture of the proximal phalanx of the hallux (big toe) develop a neuroma of the dorsal cutaneous nerve?

Neuroma Development Following Nondisplaced Intra-articular Fracture of Proximal Phalanx Hallux

Yes, a nondisplaced intra-articular fracture of the proximal phalanx of the hallux can lead to neuroma formation of the dorsal cutaneous nerve, particularly if the nerve is damaged during the injury or subsequent treatment. 1

Mechanism of Neuroma Formation

• The dorsomedial cutaneous nerve of the hallux (a terminal branch of the superficial fibular nerve) crosses the extensor hallucis longus tendon in the dorsal aspect of the hallux, making it vulnerable to injury during both trauma and surgical interventions 1
• Neurologic pain can develop from nerve irritation or entrapment following trauma to the foot, including fractures of the proximal phalanx 2
• Iatrogenic or traumatic injuries to the dorsomedial cutaneous nerve can result in:
  • Sensory loss in the affected area
  • Neuroma formation
  • Debilitating causalgia (burning pain) 1

Risk Factors for Neuroma Development

• Surgical intervention for fracture fixation increases the risk of nerve damage and subsequent neuroma formation 1
• Even with nondisplaced intra-articular fractures, the risk of subsequent displacement is 30-50% if treated conservatively, often necessitating surgical intervention 3
• Surgical approaches for proximal phalanx fractures, including plate fixation for unstable fractures, can place the dorsal cutaneous nerve at risk 4

Diagnostic Considerations

• If neurologic pain is suspected following hallux fracture, diagnostic studies should include:
  • Electromyography
  • Nerve conduction velocity studies
  • Magnetic resonance imaging 2
• Ultrasonography can be used to identify the intersection of the dorsomedial cutaneous nerve and the extensor hallucis longus tendon with 75% sensitivity, which may help in preoperative planning or post-injury assessment 1

Treatment Implications

• For nondisplaced intra-articular fractures of the proximal phalanx, treatment options include:
  • Surgical fixation (preferred) - using multiple screws or sliding screws to prevent displacement 3
  • Conservative management - with regular radiographic follow-up, but higher risk of displacement 3
• If neuroma develops:
  • Referral to a podiatric foot and ankle surgeon is recommended for local nerve conditions 2
  • Neurologic pain may require specialized management beyond fracture care 2

Prevention Strategies

• Preoperative identification of the dorsomedial cutaneous nerve using ultrasonography can help prevent iatrogenic nerve injury during surgical procedures 1
• Careful surgical technique with minimal dissection is crucial to avoid nerve damage 4
• Early mobilization following appropriate fracture fixation may help prevent nerve entrapment in scar tissue 4

Common Pitfalls

• Failure to recognize neurologic pain as a distinct entity from mechanical or inflammatory pain following fracture 2
• Inadequate imaging workup when patients present with persistent pain after apparent fracture healing 2
• Delayed diagnosis of neuroma can lead to chronic pain and disability 1