What is the treatment for a fractured first metatarsal phalange (big toe)?

Treatment of Broken Big Toe (First Metatarsal Phalange Fracture)

For most nondisplaced big toe fractures, immobilize with a hard-soled shoe or walking boot for 2-6 weeks with weight-bearing as tolerated, and buddy tape the toe to the second toe for additional stability. 1

Immediate Assessment

Before initiating treatment, check for these critical findings that require emergency referral:

• Blue, purple, or pale appearance of the toe indicates compromised circulation and requires immediate emergency activation 2
• Open wounds associated with the fracture should be covered with a clean dressing before any immobilization to reduce contamination risk 2
• Severe deformity or visible protruding bone warrants urgent orthopedic consultation 2

Diagnostic Imaging

• Obtain three-view radiographs (anteroposterior, lateral, and oblique) of the foot to confirm the fracture and assess displacement 2, 1
• Weight-bearing films are preferred when the patient can tolerate them, as they provide critical information about fracture stability 2
• If initial radiographs are negative but clinical suspicion remains high, consider repeat films in 10-14 days 3

Treatment Protocol

For Nondisplaced Fractures (Most Common)

Immobilization:

• Use a hard-soled shoe or short leg walking boot for 2-6 weeks depending on pain and fracture healing 1
• The great toe requires particular attention due to its critical weight-bearing role 1

Buddy Taping Technique:

• Clean and dry both the injured big toe and adjacent second toe before taping 4
• Apply non-elastic adhesive tape around both toes, wrapping firmly enough for stability but not so tight as to compromise circulation 4
• Check capillary refill after taping to ensure adequate circulation 4
• If an open wound is present, cover it with a clean dressing before applying tape 4

Weight-Bearing:

• Allow weight-bearing as tolerated based on the patient's pain level 1
• Most patients can bear weight immediately with appropriate immobilization 1

For Displaced or Unstable Fractures

Splinting in the acute setting:

• Splinting reduces pain, prevents further injury, and facilitates transport to definitive care 2
• Treat the deformed extremity in the position found unless straightening is necessary for safe transport 2
• Refer immediately to orthopedic surgery for potential operative fixation 1

Adjunctive Measures

Ice therapy:

• Apply melting iced water through a wet towel for repeated 10-minute intervals rather than continuous application 5
• This achieves target temperature reduction of 10-15°C while avoiding skin compromise 5
• Caution: Motor function is impaired for up to 30 minutes after ice treatment, increasing reinjury risk 5

Compression:

• While compression may provide comfort for ankle injuries, evidence for toe fractures specifically is limited 2
• If used, ensure the wrap is not overtightened to avoid compromising circulation 2

Critical Pitfalls to Avoid

• Monitor for rotational deformity with serial clinical examinations, particularly in oblique fracture patterns 3
• Ensure immobilization compliance: Removable boots allow non-adherence, leading to delayed union or malunion 3
• Do not immobilize for excessive periods: Unlike ankle sprains, toe fractures require specific immobilization duration (2-6 weeks maximum) to prevent stiffness and adhesion formation 1
• Avoid manipulation of the fracture prior to radiographs unless there is neurovascular compromise or critical skin injury 2

Follow-Up

• Reassess clinically at 2 weeks to evaluate healing progress and pain improvement 1
• Repeat radiographs if clinical healing is not progressing as expected 3
• Most toe fractures heal within 4-6 weeks with appropriate conservative management 1

When to Refer to Orthopedics

Immediate referral is indicated for:

• Displaced fractures requiring reduction 1
• Intra-articular fractures of the metatarsophalangeal joint 1
• Open fractures 2
• Fractures with neurovascular compromise 2
• Failure to heal with conservative management 1