Treatment of Great Toe (D1) Phalanx Fracture
Most great toe phalanx fractures should be treated conservatively with buddy taping to the second toe and a rigid-sole shoe, but displaced fractures, open fractures (especially those with nail bed injury suggesting a Seymour fracture), and fractures involving >25% of the joint surface require orthopedic referral for potential operative fixation. 1
Initial Assessment and Imaging
Obtain anteroposterior and oblique radiographs of the great toe to identify the fracture pattern, assess displacement, and evaluate for intra-articular involvement. 1 A standard 3-view examination is most appropriate for phalangeal injuries. 2
Critical Red Flags Requiring Immediate Referral
- Bleeding at the nail base or laceration proximal to the nail fold with a physeal fracture signals a likely open Seymour fracture of the distal phalanx—these are frequently missed and can lead to osteomyelitis or growth arrest if not promptly treated. 3, 4
- Circulatory compromise (blue, purple, or pale toe) requires emergency evaluation. 2
- Open fractures with significant soft tissue injury. 1
- Fracture-dislocations or displaced intra-articular fractures. 1
- Displaced fractures involving >25% of the joint surface. 1
Treatment Algorithm by Fracture Type
Stable, Nondisplaced Fractures (Most Common)
Treat with buddy taping and rigid-sole shoe to limit joint movement and allow healing. 1 This conservative approach is preferred for stable, extra-articular fractures. 5
- Buddy tape the great toe to the second toe with padding between digits
- Use a rigid-sole or post-operative shoe to minimize motion at the fracture site
- Weight-bearing as tolerated
- Follow-up in 1-2 weeks to reassess alignment
Displaced Fractures of the Great Toe
Refer to orthopedic surgery for reduction and stabilization. 1 Unlike lesser toe fractures that can often be reduced and buddy-taped by primary care, displaced great toe fractures frequently require operative fixation to maintain reduction. 1
Open Physeal Fractures (Seymour Fractures)
These require urgent surgical intervention within 2-3 days to prevent complications. 6, 4
- High index of suspicion when a physeal fracture of the great toe is associated with bleeding or nail bed injury—40% are initially missed by providers. 6
- Surgical options include suture-only stabilization or K-wire fixation after irrigation, debridement, and nail bed repair. 6
- Delayed recognition increases risk of osteomyelitis, malunion, nail deformity, and physeal arrest. 3, 4
Pediatric Physeal Fractures
Most children with physeal fractures should be referred to orthopedics, but selected nondisplaced Salter-Harris types I and II fractures may be treated conservatively by family physicians with close follow-up. 1
Common Pitfalls to Avoid
- Missing open fractures: Any "stubbed toe" with bleeding at the nail base or proximal nail fold laceration should raise suspicion for an open Seymour fracture, even if the fracture appears minimally displaced on X-ray. 3, 4
- Inadequate immobilization: Regular shoes do not provide sufficient immobilization—a rigid-sole shoe is essential. 1
- Failure to reassess: Repeat radiographs at 10-14 days if clinical suspicion remains high despite negative initial films. 2
- Underestimating great toe importance: The great toe bears significant weight-bearing load; inadequate treatment can lead to chronic pain and functional impairment. 1
When Conservative Management Fails
If pain persists beyond expected healing time (typically 4-6 weeks) or if there is evidence of malunion or nonunion on follow-up radiographs, refer to orthopedic surgery for evaluation of delayed operative fixation. 5