Treatment of Fractured Toes
Most toe fractures should be treated conservatively with buddy taping and a rigid-sole shoe for 4-6 weeks, without the need for fracture clinic follow-up in stable, nondisplaced cases. 1, 2
Initial Assessment and Red Flags
When evaluating a suspected toe fracture, immediately assess for conditions requiring urgent referral 1:
- Circulatory compromise (blue, purple, or pale digit) - activate emergency response immediately 3
- Open fractures with visible bone or severe bleeding 3, 1
- Significant soft tissue injury 1
- Fracture-dislocations 1
- Displaced intra-articular fractures involving >25% of joint surface 1
Diagnostic Approach
Obtain anteroposterior and oblique radiographs to identify the fracture, assess displacement, and evaluate adjacent structures 1, 2. Weight-bearing films are preferred when tolerated 2. The Ottawa foot and ankle rules can guide the need for imaging after acute injury 2.
Treatment by Fracture Type
Great Toe (Hallux) Fractures
The great toe requires special attention due to its critical role in weight-bearing 2:
- Stable, nondisplaced fractures: Short leg walking boot or cast with toe plate for 2-3 weeks, then rigid-sole shoe for additional 3-4 weeks 4
- Displaced or unstable fractures: Often require orthopedic referral for stabilization 1
- Fractures involving >25% of joint surface: Refer to orthopedics 1
Lesser Toe Fractures (2nd-5th Toes)
Most lesser toe fractures are managed nonsurgically 2, 5:
- Stable, nondisplaced fractures: Buddy taping to adjacent toe plus rigid-sole shoe for 4-6 weeks 1, 2, 4
- Displaced fractures: Perform closed reduction, then buddy tape and use rigid-sole shoe 1
- Weight-bearing: As tolerated based on pain level 2
Pediatric Considerations
Most children with physeal (growth plate) fractures should be referred to orthopedics 1. However, selected nondisplaced Salter-Harris type I and II fractures may be managed by primary care physicians with buddy taping and rigid-sole shoe 1.
Key Management Principles
Immobilization should NOT include the ankle joint - this is unnecessary and prolongs recovery 5. The evidence shows that:
- Long-term immobilization is not needed for nondisplaced fractures 5
- A compressive dressing or rigid-sole shoe provides adequate support 2, 4
- Early mobilization as pain allows is appropriate 2
Follow-Up and Referral
Most stable toe fractures do not require fracture clinic follow-up 6. A study of 707 fracture clinic patients found that only 2 of 65 patients with toe fractures required surgery, and no patients developed symptomatic malunion requiring intervention over 2 years 6. This suggests that undisplaced, stable toe fractures can be managed entirely in primary care without specialty referral 6.
Indications for Orthopedic Referral 1, 5
- Intra-articular displacement with >10° angulation 5
- Shortening of 3-5mm affecting metatarsal head position 5
- Open fractures 1
- Vascular compromise 3, 1
- Fracture-dislocations 1
- Most pediatric physeal fractures 1
Common Pitfalls
Avoid over-referral: The evidence demonstrates that 52% of toe fracture clinic appointments could be eliminated by managing stable fractures in primary care 6. Additionally, 13% of patients failed to attend their first fracture clinic appointment for toe fractures, suggesting these injuries may not warrant specialty care 6.
Watch for complications including malunion, nonunion, arthritis, infection, and compartment syndrome, though these are rare with appropriate conservative management 2.