For a fractured toe, should I consult a podiatrist or an orthopedic specialist for treatment?

Fractured Toe: Podiatry or Orthopedics?

For most toe fractures, initial evaluation and treatment can be managed by either a podiatrist or primary care physician without requiring orthopedic referral, as the vast majority are stable injuries that heal well with conservative management.

When Primary Care or Podiatry is Appropriate

Most toe fractures are straightforward injuries that do not require subspecialty orthopedic consultation. Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe, which can be managed by primary care physicians or podiatrists 1. The American College of Foot and Ankle Surgeons guidelines specifically recommend that podiatric foot and ankle surgeons manage local foot conditions, including traumatic injuries 2.

Conservative Management Criteria

• Lesser toe fractures (toes 2-5) with minimal displacement can be treated with buddy taping and a hard-soled shoe for 4-6 weeks 3, 4
• Undisplaced and stable toe phalangeal fractures do not need fracture clinic referral, as demonstrated by research showing only 2 of 65 patients with toe fractures required surgery 5
• Most toe fractures heal successfully without residual deformity or symptoms when managed conservatively 5

When Orthopedic Referral is Mandatory

Immediate orthopedic consultation is required for:

• Great toe (hallux) fractures that are unstable or involve more than 25% of the joint surface 1
• Displaced fractures of the first toe, which often require stabilization of the reduction 1
• Open fractures with skin compromise 1
• Fracture-dislocations 1
• Displaced intra-articular fractures 1
• Circulatory compromise or significant soft tissue injury 1
• Most pediatric physeal (growth plate) fractures, except selected nondisplaced Salter-Harris types I and II fractures 1

Diagnostic Approach

Initial Imaging

Obtain anteroposterior and oblique radiographs to identify fractures, determine displacement, and evaluate adjacent structures 1. Standard three-view radiographic studies (AP, lateral, and oblique) have 99% sensitivity for detecting foot fractures 6.

Important Caveat

The Ottawa rules do not address toe fractures specifically 6. If a toe fracture is suspected based on point tenderness at the fracture site or pain with gentle axial loading, radiographs should be obtained 2.

Clinical Decision Algorithm

1. Assess fracture location: Great toe versus lesser toes
2. Evaluate stability: Displaced versus nondisplaced
3. Check for complications: Open fracture, vascular compromise, significant soft tissue injury
4. Determine joint involvement: Intra-articular versus extra-articular

For Lesser Toes (2-5):

• Nondisplaced → Buddy taping + rigid-sole shoe (primary care/podiatry) 1, 3
• Displaced → Reduction + buddy taping (primary care/podiatry) 1

For Great Toe:

• Nondisplaced and stable → Short leg walking boot or cast with toe plate for 2-3 weeks, then rigid-sole shoe for 3-4 weeks (primary care/podiatry) 3
• Displaced, unstable, or >25% joint involvement → Orthopedic referral 1

Common Pitfalls to Avoid

• Do not underestimate great toe fractures: The hallux plays a critical role in weight-bearing, and displaced or unstable fractures require orthopedic management 1, 3
• Do not routinely refer all toe fractures to orthopedics: Research shows 52% of toe fracture appointments could be eliminated by managing stable fractures in primary care 5
• Do not miss pediatric growth plate injuries: Most physeal fractures require orthopedic consultation 1
• Do not delay referral for open fractures or vascular compromise: These require urgent surgical evaluation 1