What is the best course of treatment for an 8-year-old with a big toe injury?

Management of Big Toe Injury in an Eight-Year-Old

For an 8-year-old with a big toe injury, obtain anteroposterior and oblique radiographs of the foot to identify fractures and assess displacement, then treat most stable, nondisplaced fractures with buddy taping and a rigid-sole shoe, while referring displaced fractures, fractures involving >25% of the joint surface, or physeal injuries for specialist evaluation. 1

Initial Assessment and Imaging

The first step is determining whether imaging is needed and what type:

• Obtain radiographs of the foot (anteroposterior and oblique views) as the most appropriate initial imaging for children with localized foot symptoms 2
• These views are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges 1
• Consider weight-bearing radiographs when tolerated in children older than 5 years with suspected foot abnormality 2
• If initial radiographs are normal but symptoms persist, MRI may be necessary 2

Clinical Examination Findings

Look for these specific signs to guide management:

• Point tenderness at the fracture site or pain with gentle axial loading of the digit indicates likely fracture 1
• Assess for mechanism: crushing injury, axial force (stubbing), or hyperextension injury 1, 3
• Evaluate for signs requiring urgent referral: circulatory compromise, open fracture, significant soft tissue injury, or fracture-dislocation 1

Treatment Based on Fracture Type

Non-Displaced, Stable Fractures (Most Common)

Treat with buddy taping and rigid-sole shoe:

• Buddy tape the injured toe to the adjacent toe to limit joint movement 1
• Provide a rigid-sole shoe (or stiff-soled footwear) to restrict motion and protect the toe 1
• This approach is appropriate for most stable, nondisplaced toe fractures 1

Displaced Fractures of Lesser Toes

• Perform reduction followed by buddy taping 1
• These can typically be managed by primary care physicians 1

Fractures Requiring Specialist Referral

Refer immediately for:

• Displaced fractures of the first toe (great toe) - often require stabilization of the reduction 1
• Fractures involving more than 25% of the joint surface 1
• Unstable fractures of the first toe 1
• Open fractures or those with significant soft tissue injury 1
• Fracture-dislocations 1
• Displaced intra-articular fractures 1
• Circulatory compromise 1

Physeal (Growth Plate) Injuries

• Most children with physeal fractures should be referred to orthopedics 1
• Exception: Selected nondisplaced Salter-Harris type I and II fractures may be treated by primary care with buddy taping and rigid-sole shoe 1
• Growth plate injuries require careful monitoring due to potential for growth disturbance 1

Special Considerations for Hyperextension Injuries

If the mechanism involves hyperextension (such as jamming the toe upward):

• Consider turf toe injury - a sprain of the first metatarsophalangeal joint that can damage supporting soft tissues and cartilage 3, 4
• These injuries are less common in children but can occur in sports activities 4
• Most turf toe injuries are managed conservatively with rest, shoe modification, and insoles 4
• Severe cases (grade III with complete disruption) may require 4-6 weeks or more of restricted activity 5

Common Pitfalls to Avoid

• Do not miss physeal injuries - most require specialist evaluation even if nondisplaced 1
• Do not underestimate first toe fractures - these often need referral for proper stabilization unlike lesser toe fractures 1
• Do not allow barefoot walking during healing - rigid-sole shoes are essential for protection 1
• Ensure adequate follow-up - reexamine in 3-5 days if symptoms worsen or fail to improve 6