Management of 2nd Toe Fractures
Most 2nd toe fractures should be treated conservatively with buddy taping to the adjacent toe and a rigid-sole shoe for 4-6 weeks, allowing weight-bearing as tolerated. This approach is effective for stable, nondisplaced fractures which comprise the majority of toe injuries seen in primary care 1, 2.
Initial Assessment
When evaluating a suspected 2nd toe fracture, look for:
- Bony point tenderness at the fracture site 3, 1
- Pain with gentle axial loading of the digit (compress the toe tip longitudinally) 1
- Swelling and ecchymosis around the affected area 3
- Deformity or rotational malalignment suggesting displacement 1
Obtain anteroposterior and oblique radiographs to identify the fracture, assess displacement, and evaluate adjacent structures 1. Weight-bearing views are recommended when feasible 3.
Treatment Algorithm
For Stable, Nondisplaced Fractures (Most Common)
- Buddy tape the 2nd toe to the 3rd toe with gauze padding between digits to prevent skin maceration 1, 2
- Prescribe a rigid-sole shoe or hard-soled shoe to limit joint movement and protect the fracture 1, 2
- Allow weight-bearing as tolerated based on patient comfort 3, 1
- Continue treatment for 4-6 weeks until clinical healing 2
For Displaced Fractures
- Perform closed reduction followed by buddy taping 1
- Apply rigid-sole shoe for immobilization 1
- If reduction cannot be maintained or fracture is unstable, refer to orthopedics 1
Indications for Orthopedic Referral
Immediate referral is required for 1:
- Circulatory compromise
- Open fractures
- Significant soft tissue injury
- Fracture-dislocations
- Displaced intra-articular fractures involving >25% of joint surface
- Inability to maintain reduction after closed manipulation
Important Caveats
The 2nd toe differs from the great toe, which bears significantly more weight and requires more aggressive management with a short leg walking boot or cast for 2-3 weeks, followed by a rigid-sole shoe for an additional 3-4 weeks 2. Lesser toe fractures like the 2nd toe can be managed more conservatively 2.
Pediatric fractures involving the growth plate (physis) generally require referral, except for selected nondisplaced Salter-Harris types I and II fractures which may be managed by primary care physicians 1.
Monitor for complications including malunion, nonunion, arthritis, and infection, though these are less common in lesser toe fractures compared to metatarsal injuries 3.
The evidence consistently supports conservative management for most 2nd toe fractures, with excellent functional outcomes using simple buddy taping and protected weight-bearing 1, 2. This approach minimizes patient morbidity while allowing early mobilization and return to activities.