What is the management of a fracture of the proximal phalanx of the 5th toe?

Management of Fracture of Proximal Phalanx of 5th Toe

Treat conservatively with buddy taping to the 4th toe and immediate mobilization—this approach achieves excellent functional outcomes without the stiffness complications associated with surgical fixation. 1

Initial Assessment and Imaging

• Obtain plain radiographs to confirm the diagnosis and assess fracture pattern, displacement, and stability 1
• Examine for malrotation by assessing finger alignment in both flexion and extension 1
• Check for associated soft tissue injuries or neurovascular compromise 1

Conservative Management Protocol

Buddy taping is the treatment of choice for base fractures of the 5th proximal phalanx, allowing immediate mobilization while providing adequate stability. 1

• Perform closed reduction if the fracture is displaced 1
• Apply buddy taping to secure the 5th toe to the 4th toe 1
• Begin immediate mobilization—do not immobilize the toe in a cast or splint 1
• This approach achieves full flexion recovery in nearly all patients and satisfactory extension in the vast majority 1

A prospective study of 53 consecutive base fractures of the proximal phalanx in the 5th digit demonstrated high overall satisfaction with buddy taping, with only 4 patients reporting mild pain and only 3 cases of malrotation (none requiring surgery). 1 No nonunion or delayed union occurred, and all but one patient regained full flexion. 1

Pain Management

• Prescribe regular paracetamol (acetaminophen) routinely unless contraindicated as first-line analgesia 2
• Avoid NSAIDs entirely in patients with renal dysfunction 2
• Use opioids cautiously only if needed, with reduced dosing in patients with renal impairment 2

Follow-Up Protocol

• Schedule follow-up at 4,8, and 12 weeks or until the patient is asymptomatic 2
• Obtain serial radiographs to confirm proper bone healing 2
• Monitor for complications including malrotation, stiffness, or delayed union 1

When to Consider Surgical Intervention

Surgical fixation is rarely indicated for 5th toe proximal phalanx fractures, as internal fixation often leads to decreased mobility despite exact fracture reduction. 1 Reserve surgery only for:

• Salter-Harris type IV intraarticular fractures in pediatric patients (which carry poor prognosis and almost always require surgical reduction) 3
• Unstable fractures that cannot be maintained with closed reduction 1
• Significant malrotation that impairs function after conservative management 1

Critical Pitfalls to Avoid

• Do not immobilize the toe in a cast—this leads to stiffness without improving outcomes compared to buddy taping with immediate mobilization 1
• Do not pursue surgical fixation for routine fractures—conservative management with buddy taping achieves excellent functional results with lower complication rates 1
• Do not delay pain assessment and management, as early analgesia is crucial 2
• Do not prescribe NSAIDs without checking renal function first 2
• Do not use standard opioid dosing without considering renal function and age-related dose adjustments 2