Treatment of Distal Phalanx (Toe) Subluxation
For a distal phalanx subluxation of the toe, perform closed reduction with gentle repositioning and immobilization, ensuring the toe does not interfere with normal bite/occlusion, followed by observation for healing.
Initial Assessment and Management
Immediate Reduction
- Perform gentle repositioning of the subluxated toe immediately to restore anatomic alignment 1
- Ensure that after reduction, the posterior teeth (molars) can fully interdigitate and the patient can masticate properly without interference from the malpositioned digit 1
- Ask the patient to gently bite down or bear weight to assess whether the toe position interferes with normal function 1
Immobilization Strategy
- Use removable offloading devices or toe spacers depending on the specific location and severity of the subluxation 1
- For non-plantar toe injuries, employ removable offloading devices, footwear modifications, toe spacers, or orthoses based on the type and location 1
- Consider digital flexor tenotomy for flexible toe deformities (digits 2-5) if conservative treatment fails 1
Surgical Considerations
When Conservative Treatment Fails
- For neuropathic plantar or apex ulcers on digits 2-5 secondary to flexible toe deformity, use digital flexor tenotomy to promote healing and prevent recurrence 1
- Consider digital flexor tenotomy when conservative treatment fails in patients with hammertoes and either pre-ulcerative signs or ulcers on the distal toe 1
- For severe displacement (>3mm) or cases where the subluxation interferes significantly with ambulation, immediate referral to orthopedic or podiatric surgery is indicated 1
Special Fracture Considerations
- If the subluxation is associated with an open physeal fracture (Seymour fracture equivalent in the toe), this requires urgent surgical intervention with irrigation, debridement, and stabilization to prevent osteomyelitis, malunion, or premature growth arrest 2, 3
- Suture-only stabilization represents a simple, reliable alternative to pin fixation for open physeal fractures of the great toe distal phalanx 2
Follow-Up and Monitoring
Observation Protocol
- Monitor for signs of complications including persistent pain, inability to wear shoes, or development of chronic deformity 1
- Assess for proper healing and return of function, particularly the ability to wear normal footwear 1
- Be aware that contractures may recur, especially in patients with underlying connective tissue disorders 1
Common Pitfalls to Avoid
- Do not use conventional or standard therapeutic shoes alone for treatment, as these provide inadequate offloading 1
- Avoid delayed treatment, as this can lead to chronic subluxation, difficulty with footwear, and persistent pain 1
- Do not overlook associated nail bed injuries or soft tissue damage that may indicate a more complex injury requiring surgical intervention 2, 3