Do we need to splint a non-displaced fracture of the great toe in a 19-month-old?

Management of Non-Displaced Great Toe Fracture in a 19-Month-Old

For a non-displaced great toe fracture in a 19-month-old, immobilization with buddy taping and a rigid-sole shoe is recommended, though recent evidence suggests that conservative management without rigid immobilization may be equally effective and associated with fewer complications. 1, 2

Recommended Treatment Approach

Primary Management Strategy

• Buddy taping to the adjacent toe with a rigid-sole shoe is the traditional standard of care for stable, non-displaced toe fractures in children 2
• The rigid-sole shoe limits joint movement and provides protection during the healing phase 2
• Consider conservative management without rigid immobilization as an alternative, given emerging evidence that immobilization may not reduce fracture-related complications and can cause immobilization-related adverse events 3

Rationale for Conservative Approach

• Pediatric patients have exceptional remodeling potential, which mitigates the risk of residual deformity even with initial acceptance of some deformity 4
• In a systematic review of undisplaced distal tibial fractures in young children (toddler's fractures), there was no significant difference in fracture-related adverse events between immobilized and non-immobilized groups (risk difference 0.00,95% CI -0.01 to 0.02) 3
• However, 14.7% of immobilized children experienced immobilization-related complications including skin irritation, stiffness, and muscle atrophy 3

Key Clinical Considerations

When to Consider Referral

Referral to pediatric orthopedics is NOT typically needed for non-displaced great toe fractures, but should be considered if: 2

• Circulatory compromise is present 2
• Open fracture or significant soft tissue injury 2
• Fracture-dislocation or displaced intra-articular fracture 2
• Fracture involves >25% of the joint surface 2
• Instability is present on examination 2

Special Considerations for This Age Group

• At 19 months, the child is in the toddler age range where fractures typically heal rapidly with minimal complications 3
• Communication of pain is limited at this age, so monitor for behavioral changes including anxiety, agitation, and increased analgesic requirements 4
• Normal compartment pressures are higher in children (13-16 mmHg vs. 0-10 mmHg in adults), though compartment syndrome is exceedingly rare with isolated toe fractures 4

Follow-Up Protocol

Imaging Recommendations

• Routine serial radiographs are NOT necessary for stable, non-displaced fractures healing appropriately 1
• Repeat imaging should only be obtained if there is new trauma, increased pain, loss of range of motion, or neurovascular symptoms 1
• If initial radiographs are equivocal but clinical suspicion remains high, consider repeat films in 10-14 days 5

Clinical Monitoring

• Assess for appropriate weight-bearing and return to normal activity 3
• Monitor for signs of delayed healing or complications 1
• Ensure compliance with treatment plan, as non-adherence can lead to delayed union 5

Common Pitfalls to Avoid

• Do not miss open physeal fractures with nail bed injury (Seymour fractures), which require surgical intervention to prevent infection, nail deformity, and physeal arrest 6
• Avoid prolonged immobilization, which may lead to unnecessary stiffness, muscle atrophy, and delayed return to activities 4, 3
• Do not routinely obtain follow-up radiographs unless clinically indicated, as this increases healthcare contacts without changing management 1
• Be aware that intra-articular fractures of the great toe have high complication rates with surgical intervention, so conservative management is preferred when appropriate 7