Treatment of Distal Phalanx Fracture of the Great Toe
For closed, nondisplaced distal phalanx fractures of the great toe, treat conservatively with buddy taping or a rigid-soled shoe and immediate active toe motion exercises; however, for open fractures with nail bed injury (Seymour fractures) or displaced fractures (>3mm), surgical intervention with irrigation, debridement, and stabilization is mandatory to prevent osteomyelitis and growth disturbances.
Critical Initial Assessment
The mechanism of "stubbing" the great toe with any of the following findings indicates a likely open fracture requiring urgent surgical management 1, 2, 3:
- Bleeding at the base of the nail
- Laceration proximal to the nail fold
- Displaced physeal fracture on radiograph
- Any soft tissue injury overlying the fracture site
These injuries are frequently missed by initial providers (40% in one series), leading to delayed treatment and complications including osteomyelitis, physeal arrest, and nail deformities 1, 3.
Treatment Algorithm
For Closed, Nondisplaced Fractures
Conservative management is appropriate 4:
- Buddy taping to adjacent toe or rigid-soled shoe for comfort
- Initiate active toe motion exercises immediately to prevent stiffness 5
- Ice application at 3 and 5 days post-injury for symptomatic relief 5
- Radiographic follow-up at approximately 3 weeks to confirm healing 5
- Most distal phalanx fractures from crushing injuries require care for surrounding soft tissues but rarely need specific fracture treatment 4
For Open Fractures (Seymour Fractures of the Great Toe)
Urgent surgical intervention is mandatory 1, 2, 3:
- Perform irrigation and debridement of the open wound
- Remove the nail plate to inspect and repair the nail bed injury
- Reduce the fracture (often requires open reduction due to soft tissue interposition) 1, 2
- Suture-only stabilization is a simple, reliable alternative to K-wire fixation with no reported infections or physeal bars in recent series 1
- K-wire fixation is an alternative option, though carries risk of migration and requires a second procedure for removal 1, 2, 6
- Mean time from injury to surgery should be minimized (ideally <3 days) to reduce infection risk 1
For Displaced Intra-articular Fractures
Surgical intervention is indicated when displacement >3mm is present 5, 6:
- Open reduction is frequently necessary (required in 9 of 10 cases in one series) 6
- K-wire fixation is typically used for stabilization 6
- However, be aware that intra-articular fractures of the great toe have a high complication rate (60% in one series) including nonunion, refracture, posttraumatic arthritis, and avascular necrosis 6
- Despite complications, most patients return to full activity without limitation at long-term follow-up 6
Common Pitfalls and How to Avoid Them
Delayed diagnosis is the most critical pitfall 1, 3:
- Maintain high suspicion for open fracture when any nail bed injury or bleeding accompanies a great toe injury
- Do not dismiss these as simple "stubbed toe" injuries
- Obtain radiographs in multiple views to identify physeal fractures
Attempting closed reduction in clinic for displaced open fractures often fails 2:
- Digital blocks are insufficient for adequate reduction when soft tissue is interposed
- Proceed directly to operative management rather than attempting multiple closed reduction attempts
K-wire complications occur frequently 6:
- Monitor for wire migration requiring early removal
- Consider suture-only stabilization as a simpler alternative for Seymour fractures 1
Post-Treatment Monitoring
- Monitor for immobilization-related complications (skin irritation, muscle atrophy) which occur in approximately 14.7% of cases 5
- For operative cases, follow-up imaging should confirm fracture healing at approximately 7-8 weeks 6
- Watch for signs of infection, physeal arrest, or nail deformity in open fractures 1, 3