Fifth Toe Fractures: Complications and Management
Most fifth toe fractures are stable and can be managed conservatively with buddy taping and a rigid-sole shoe, but displaced fractures, open fractures, or those involving significant soft tissue injury require orthopedic referral. 1
Initial Evaluation and Imaging
- Obtain anteroposterior and oblique radiographs to identify the fracture, assess displacement, and evaluate adjacent structures 1, 2
- Look for point tenderness at the fracture site or pain with gentle axial loading of the digit 1
- Weight-bearing radiographs provide additional information when clinically feasible 2
- The Ottawa foot rules can guide imaging decisions in the broader context of foot trauma, though toe fractures specifically warrant radiographs when clinically suspected 3, 2
Indications for Orthopedic Referral
Refer immediately for:
- Circulatory compromise 1
- Open fractures 1
- Significant soft tissue injury 1
- Fracture-dislocations 1
- Displaced intra-articular fractures 1
- Fractures involving more than 25% of the joint surface 1
- Displaced fractures requiring stabilization 1
Conservative Management for Stable Fractures
For stable, nondisplaced fractures:
- Buddy tape the affected toe to the adjacent toe 1, 2
- Use a rigid-sole or hard-soled shoe to limit joint movement 1, 2
- Duration of immobilization: 2-6 weeks depending on pain level and fracture stability 2
- Weight-bearing as tolerated based on patient comfort 2
Potential Complications
Common complications to monitor:
- Malunion or nonunion - particularly concerning in fractures with poor initial alignment 2
- Post-traumatic arthritis - especially with intra-articular involvement 2
- Infection - higher risk with open fractures 2
- Chronic pain and deformity - may develop with inadequate initial treatment 2
- Overlapping or underlapping toe deformities - can occur as late sequelae, though these are more commonly congenital 4
Pediatric Considerations
- Most children with physeal (growth plate) fractures should be referred to orthopedics 1
- Selected nondisplaced Salter-Harris type I and II fractures may be managed by primary care physicians with buddy taping and close follow-up 1
- Congenital deformities like overlapping or underlapping fifth toes often correct spontaneously with normal ambulation up to age 6 and require intervention only if symptomatic 4
Common Pitfalls
- Failing to obtain adequate radiographs - oblique views are essential as anteroposterior views alone may miss fractures 1
- Missing associated soft tissue injuries - always assess neurovascular status and skin integrity 1
- Inadequate immobilization - regular athletic shoes do not provide sufficient rigidity; a hard-soled shoe or boot is necessary 1, 2
- Delayed recognition of complications - schedule follow-up at 1-2 weeks to assess healing and alignment 2