What is the appropriate management for a patient with a great toe injury, presenting with erythema (redness), pain on palpation, and limited mobility, but no deformity?

Management of Great Toe Injury with Erythema, Pain, and Preserved Mobility

This patient requires immediate evaluation for possible infection or compartment syndrome, with urgent imaging and close monitoring for progression—do not assume this is a simple contusion given the erythema and pain on palpation. 1

Immediate Assessment Priorities

Rule Out Limb-Threatening Conditions First

The presence of erythema with pain on palpation mandates urgent evaluation for:

• Compartment syndrome: Pain out of proportion to clinical findings is a red flag for this surgical emergency 1, 2
• Deep space infection or abscess: Unexplained persistent foot pain or tenderness, even without fever or leukocytosis, requires surgical evaluation 1
• Rapidly progressive infection: Erythema spreading beyond the immediate injury site suggests potential fascial compartment involvement 1

Key examination findings to assess immediately:

• Measure compartment pressures if pain seems disproportionate to visible injury 2
• Check for pain with passive stretch of the toe (suggests compartment syndrome) 2
• Assess neurovascular status—paresthesias or paresis are concerning 2
• Document the extent of erythema with marking to monitor progression 1
• Palpate for fluctuance suggesting abscess formation 1

Diagnostic Imaging Algorithm

Step 1: Obtain Plain Radiographs Immediately

• Anteroposterior and oblique views of the foot to evaluate for fracture, even if no deformity is visible 3
• Look specifically for:
  • Displaced or intra-articular fractures requiring referral 3
  • Joint involvement (>25% of joint surface in great toe requires orthopedic consultation) 3
  • Subtle fractures that may not be clinically obvious 3

Step 2: If Radiographs Are Normal But Pain Persists

• MRI without contrast is the preferred next study if pain continues beyond 1 week with normal X-rays 4
• MRI will identify occult fractures, ligamentous injuries, or soft tissue pathology not visible on plain films 4

Treatment Based on Clinical Scenario

If Infection Is Suspected (Erythema + Pain + Transfer Injury)

Urgent surgical consultation is mandatory if any of the following are present 1:

• Erythema extending >1.5 cm beyond the injury site
• Systemic signs (fever, tachycardia, elevated WBC)
• Rapid progression of symptoms
• Pain out of proportion to examination findings

Initial management while awaiting surgical evaluation:

• Obtain blood cultures and wound cultures if any break in skin 1
• Start empiric IV antibiotics (amoxicillin-clavulanic acid covers most diabetic foot pathogens) 1
• Keep patient non-weight bearing 1
• Elevate the foot 1

If Simple Soft Tissue Injury (No Infection Signs)

For stable injuries without fracture or infection:

• Buddy taping to adjacent toe for stability 3
• Rigid-sole shoe to limit joint movement 3
• Ice and elevation for first 48-72 hours 1
• NSAIDs for pain control 1
• Activity modification: Avoid push-off activities that stress the MTP joint 5

Expected recovery timeline:

• Most soft tissue injuries to the great toe require 6 months for full recovery 5
• Loss of dorsiflexion is the most common residual problem 5
• Persistent discomfort occurs in approximately 40% of cases 5

Critical Red Flags Requiring Immediate Referral

Do not delay surgical consultation if any of these develop 1:

• Blue or extremely pale toe (vascular compromise) 1
• Inability to move the toe (new finding suggesting compartment syndrome) 2
• Crepitus on examination 1
• New onset numbness in the toe 1
• Worsening erythema despite initial treatment 1
• Bullae or hemorrhagic blisters 1

Follow-Up Protocol

Reexamination Timing

• Reexamine at 3-5 days post-injury as excessive initial swelling can limit the first examination 6
• If no improvement after 6 weeks of conservative treatment, obtain MRI and consider orthopedic referral 4

When to Obtain Advanced Imaging

• Pain persisting >1 week with normal radiographs warrants MRI 4
• Consider bone scan if stress fracture suspected but radiographs negative 6

Common Pitfalls to Avoid

• Never assume absence of fever or leukocytosis rules out serious infection—diabetic patients and immunocompromised individuals may not mount typical inflammatory responses 1
• Do not immobilize in a splint without first ruling out compartment syndrome—this can delay diagnosis of a surgical emergency 2
• Avoid corticosteroid injections near the great toe MTP joint—risk of joint damage and infection 6
• Do not discharge without clear return precautions—instruct patient to return immediately if erythema spreads, pain worsens, or systemic symptoms develop 1

Given this patient's mechanism (transfer to bed) with resulting erythema and pain, the most concerning diagnosis is evolving infection or compartment syndrome, both of which require urgent evaluation and cannot be managed conservatively without first excluding these limb-threatening conditions. 1, 2