How to manage a Salter Harris type 2 fracture of the proximal phalanx of the 5th toe in an 8-year-old child?

Management of Salter-Harris Type 2 Fracture of the Proximal Phalanx of the 5th Toe in an 8-Year-Old

Conservative management with buddy taping to the 4th toe and a rigid-sole shoe is the appropriate treatment for this injury, with immobilization for 3-4 weeks and clinical follow-up only if symptoms persist. 1, 2

Initial Assessment and Imaging

• Confirm the diagnosis with anteroposterior and oblique radiographs of the foot to identify the fracture pattern, assess for displacement, and evaluate adjacent structures 1
• Examine for signs of an open fracture: bleeding at the nail base, lacerations proximal to the nail fold, or obvious displacement through the physis, which would require urgent referral 3
• Assess for rotational deformity by observing the digital cascade with the fingers flexed—all toes should point toward the scaphoid when flexed 4
• Check for neurovascular compromise, which mandates immediate referral 1

Treatment Protocol

For stable, nondisplaced or minimally displaced Salter-Harris type 2 fractures of the 5th toe proximal phalanx:

• Buddy tape the 5th toe to the 4th toe with cotton or gauze padding between the toes to prevent skin maceration 1, 2
• Provide a rigid-sole shoe or post-operative shoe to limit joint movement and protect the fracture during weight-bearing 1
• Allow immediate weight-bearing as tolerated—these fractures are stable and do not require non-weight-bearing status 1, 2
• Continue buddy taping for 3-4 weeks until clinical healing is evident 1, 2

Follow-Up Strategy

• Minimize in-person follow-up visits—most toe fractures heal uneventfully without complications 5, 1
• Avoid routine post-treatment radiographs unless there is clinical concern for malunion or persistent symptoms, as imaging rarely changes management 5
• Schedule follow-up only if pain persists beyond 4 weeks or if parents report concerns about alignment or function 5, 1
• Consider telehealth follow-up at 2-3 weeks to assess symptoms and ensure appropriate healing trajectory 5

Indications for Referral

Refer to orthopedic surgery if any of the following are present:

• Displaced fractures that cannot be reduced with gentle manipulation 1
• Open fractures with soft tissue injury or nail bed involvement 3, 1
• Fracture-dislocations or intra-articular fractures with significant displacement 1
• Rotational deformity evident on clinical examination 4
• Circulatory compromise or significant soft tissue injury 1

Key Clinical Pitfalls

• Do not routinely refer all pediatric physeal fractures—nondisplaced Salter-Harris type 1 and 2 fractures of the lesser toes can be safely managed by primary care physicians 1
• Avoid rigid splinting or casting—these injuries do well with buddy taping alone, and excessive immobilization is unnecessary 1, 2
• Do not obtain follow-up radiographs routinely—the remodeling potential in an 8-year-old is excellent, and minor residual deformity will correct with growth 5, 2
• Be vigilant for open fractures in "stubbed toe" injuries—bleeding at the nail base or proximal lacerations indicate an open fracture requiring antibiotics and possible surgical debridement 3

Expected Outcomes

• Growth disturbances are extremely rare with Salter-Harris type 2 fractures of the 5th toe, as the injury typically does not disrupt the germinal matrix of the physis 2, 6
• Complete healing occurs within 3-4 weeks with conservative management 1, 2
• No long-term sequelae are expected with appropriate initial treatment 2, 6