What is the recommended management for great toe fractures in the emergency department?

Great Toe Fracture Management in the Emergency Department

Immediate Pain Control

Administer regular paracetamol (acetaminophen) immediately as first-line analgesia for all great toe fractures unless contraindicated. 1, 2

• Opioids may be added cautiously if paracetamol alone is insufficient, with particular attention to renal function before dosing 1, 2
• Avoid NSAIDs until renal function is confirmed, as approximately 40% of fracture patients have moderate renal dysfunction 1
• Document pain scores before and after analgesia administration to guide ongoing management 1

Critical Assessment for Open Fracture

Any great toe injury with bleeding at the nail base, laceration proximal to the nail fold, or signs of displaced physeal fracture must be treated as an open fracture until proven otherwise. 3, 4

• These "stubbed toe" injuries frequently represent open Salter-Harris fractures of the distal phalanx that are commonly missed 3, 4
• Failure to recognize open fractures leads to osteomyelitis, growth disturbances, malunion, or nonunion 3, 5, 4
• Open fractures require immediate orthopedic referral for irrigation, debridement, and possible operative fixation 3, 4

Imaging Protocol

• Obtain anteroposterior and oblique radiographs as the primary imaging modality for identifying fractures and determining displacement 5, 6
• Serial radiographs should be obtained during follow-up to confirm proper bone healing 2

Indications for Immediate Orthopedic Referral

Refer immediately for any of the following: 5, 6

• Open fractures or significant soft tissue injury 5
• Displaced intra-articular fractures involving more than 25% of the joint surface 5
• Unstable fractures of the great toe 5
• Fracture-dislocations 5
• Circulatory compromise 5
• Displaced physeal fractures (most Salter-Harris fractures except selected nondisplaced Type I and II) 5, 4

Non-Operative Management for Stable Fractures

For stable, nondisplaced great toe fractures, immobilize with a rigid-sole shoe or walking boot for 2-6 weeks. 5, 6

• Do NOT use buddy taping for great toe fractures, as the great toe requires independent immobilization due to its critical weight-bearing role 5, 6
• Weight-bearing is permitted as tolerated based on pain level 6
• Duration of immobilization depends on fracture stability and patient symptoms 6

Management of Displaced Great Toe Fractures

Displaced fractures of the great toe typically require orthopedic referral for reduction stabilization, as closed reduction often fails and operative fixation may be necessary. 3, 5

• Unlike lesser toe fractures that can be reduced and buddy-taped, great toe fractures frequently need more definitive stabilization 5
• Attempted closed reduction in the ED without orthopedic consultation risks inadequate reduction and subsequent complications 3

Common Pitfalls to Avoid

• Do not dismiss "stubbed toe" injuries with nail bed involvement as simple contusions - these are open fractures until proven otherwise 3, 4
• Do not buddy tape the great toe - it requires independent immobilization unlike lesser toes 5, 6
• Do not delay orthopedic consultation for displaced or unstable great toe fractures - these often require operative management 3, 5
• Do not prescribe NSAIDs without checking renal function first in fracture patients 1, 2