How to manage an undisplaced fracture at the base of the right great toe proximal phalanx in a patient with a history of right ankle joint fusion?

Management of Undisplaced Proximal Phalanx Fracture of the Great Toe

Treat this undisplaced fracture of the great toe proximal phalanx base conservatively with buddy taping to the second toe, a rigid-sole shoe to limit joint movement, and weight-bearing as tolerated for 4-6 weeks. 1, 2

Immediate Management

Pain Control

• Administer regular paracetamol (acetaminophen) as first-line analgesia unless contraindicated 3, 4
• Add opioids cautiously only if paracetamol is insufficient, using reduced doses if the patient has any renal dysfunction 3, 4
• Avoid NSAIDs until renal function is confirmed, as they are relatively contraindicated in patients with potential renal impairment 3, 4

Immobilization Strategy

• Apply buddy taping immediately, securing the great toe to the second toe with soft padding between the digits to prevent skin maceration 1, 2
• Provide a rigid-sole shoe or hard-soled shoe to restrict motion at the interphalangeal and metatarsophalangeal joints 1, 2
• Allow weight-bearing as tolerated, as this undisplaced fracture is stable and does not require non-weight-bearing restrictions 2

Special Considerations for This Patient

Impact of Ankle Fusion

• The patient's history of right ankle fusion with cannulated screw fixation means altered biomechanics and increased stress on the forefoot during gait 5
• This may require slightly longer immobilization (closer to 6 weeks rather than 4 weeks) to ensure adequate healing given the abnormal loading patterns 2
• Monitor closely for delayed union, as the fused ankle transfers more force through the metatarsophalangeal joints during push-off 5

Follow-Up Protocol

Clinical Assessment

• Reassess at 2 weeks to confirm the fracture remains undisplaced with repeat radiographs (anteroposterior and oblique views) 1, 2
• Continue immobilization for total of 4-6 weeks based on clinical healing (resolution of point tenderness and pain with axial loading) 1, 2
• Remove buddy taping and rigid shoe once the patient has no point tenderness and can bear weight without pain 2

Red Flags Requiring Orthopedic Referral

• Do not refer this patient unless complications develop, as stable nondisplaced fractures of the great toe proximal phalanx are managed conservatively 1
• Refer immediately if fracture displacement occurs (>2mm or >25% of joint surface involvement), as this would require surgical stabilization 1, 6
• Refer if signs of nonunion develop after 8 weeks (persistent point tenderness, inability to bear weight, or lack of radiographic healing) 6
• Refer if the patient develops signs of infection (increasing pain, erythema, warmth, or drainage), particularly given the proximity to the nail bed 7

Critical Pitfalls to Avoid

• Do not treat this as a minor injury requiring no immobilization - the great toe bears significant weight during gait, and inadequate immobilization can lead to malunion, nonunion, or posttraumatic arthritis 1, 6
• Do not assume all great toe fractures can be buddy-taped without a rigid shoe - the rigid-sole shoe is essential to limit motion at the metatarsophalangeal joint and prevent displacement 1, 2
• Do not overlook the increased risk of complications in this patient with ankle fusion - altered biomechanics may prolong healing time and increase stress on the forefoot 5
• Do not delay pain assessment - document pain scores before and after analgesia to guide ongoing management 3, 4

Expected Outcomes

• Most stable, nondisplaced great toe proximal phalanx fractures heal within 4-6 weeks with conservative management 1, 2
• The patient should return to full activity without limitation once clinical and radiographic healing is confirmed 2, 6
• Complications are uncommon with appropriate conservative management of nondisplaced fractures, unlike the high complication rate (60%) seen with surgical intervention for displaced intra-articular fractures 6