Treatment of First Proximal Phalanx Toe Fracture
Most first toe (great toe) proximal phalanx fractures that are stable and nondisplaced should be treated conservatively with buddy taping to the second toe and a rigid-sole shoe to limit joint movement, while displaced fractures often require referral for stabilization. 1
Initial Assessment and Diagnosis
Obtain anteroposterior and oblique radiographs to identify the fracture, determine displacement, and evaluate adjacent structures. 1 These views are generally most useful for complete fracture characterization.
Key Clinical Findings to Document
- Point tenderness at the fracture site 1
- Pain with gentle axial loading of the digit 1
- Degree of displacement on radiographs 1
- Stability of the fracture after any attempted reduction 1
Treatment Algorithm Based on Fracture Characteristics
Stable, Nondisplaced Fractures (Most Common)
- Buddy tape the first toe to the second toe 1
- Prescribe a rigid-sole shoe to limit joint movement 1
- Allow immediate mobilization with protected weightbearing 1
Displaced Fractures
- Refer to orthopedic surgery or podiatry for stabilization of the reduction, as these fractures often require surgical fixation 1
- Displaced fractures of the first toe are inherently unstable and typically cannot be managed conservatively 1
Fractures Requiring Immediate Referral
Refer urgently if any of the following are present:
- Circulatory compromise 1
- Open fractures 1
- Significant soft tissue injury 1
- Fracture-dislocations 1
- Displaced intra-articular fractures 1
- Fractures involving more than 25% of the joint surface 1
- Unstable fractures despite attempted reduction 1
Pain Management Protocol
Prescribe regular paracetamol (acetaminophen) routinely as first-line analgesia unless contraindicated. 2
Avoid NSAIDs in patients with any degree of renal dysfunction, as this population has high rates of renal impairment. 2
Use opioids cautiously if needed, with reduced dosing particularly in elderly patients or those with renal impairment. 2
Follow-Up and Monitoring
Obtain serial radiographs to confirm proper bone healing at 2-week intervals initially, then at 4-6 weeks. 2 This ensures early detection of displacement or nonunion.
Critical Pitfalls to Avoid
Do not treat displaced first toe fractures conservatively without orthopedic consultation, as these require stabilization that buddy taping alone cannot provide. 1 Unlike lesser toe fractures, the first toe bears significant weight and requires anatomic alignment.
Do not confuse first toe fractures with lesser toe fractures in your treatment approach—the first toe has different biomechanical demands and healing requirements. 1 Lesser toes can tolerate more displacement and malunion without functional consequences.
Do not delay pain management while awaiting definitive treatment, as early analgesia improves patient comfort and compliance. 2
Do not prescribe NSAIDs without checking renal function first, particularly in elderly patients who comprise the majority of fracture patients. 2