Management of Possible Broken Left Toe with Hypertension Requiring Medication Refill
Immediate Toe Fracture Management
For this patient with a suspected left toe fracture from a fall, buddy taping with a rigid-sole shoe is the appropriate first-line treatment, provided the fracture is stable and nondisplaced. 1, 2
Clinical Assessment of the Toe Injury
- Examine for point tenderness at the fracture site and assess pain with gentle axial loading of the digit to confirm fracture location 1
- Check for circulatory compromise, open fracture, significant soft tissue injury, or fracture-dislocation, all of which require immediate orthopedic referral 1
- Obtain anteroposterior and oblique radiographs to identify the fracture, determine displacement, and evaluate adjacent phalanges 1, 2
Treatment Algorithm Based on Radiographic Findings
For stable, nondisplaced lesser toe fractures (toes 2-5):
- Buddy tape the injured toe to the adjacent toe and provide a rigid-sole shoe to limit joint movement 1, 3
- Duration: 4-6 weeks with progressive weight-bearing as tolerated 2, 3
- Pain control with acetaminophen or NSAIDs as needed 2
For displaced lesser toe fractures:
- Perform closed reduction followed by buddy taping and rigid-sole shoe 1
- Re-evaluate in 1 week to ensure maintained alignment 3
For great toe (first toe) fractures:
- If nondisplaced and stable: short leg walking boot or cast with toe plate for 2-3 weeks, then rigid-sole shoe for additional 3-4 weeks 3
- If displaced, unstable, or involving >25% of joint surface: immediate orthopedic referral for potential surgical stabilization 1
Red Flags Requiring Urgent Orthopedic Referral
- Circulatory compromise or open fracture 1
- Fracture-dislocation or displaced intra-articular fracture 1
- Great toe fractures that are unstable or involve >25% of joint surface 1
- Significant soft tissue injury 1
Blood Pressure Medication Refill Management
Refill the patient's current antihypertensive medication immediately and verify blood pressure control at this visit. 4, 5
Blood Pressure Assessment
- Measure blood pressure in the office today to assess current control 4
- If BP <130/80 mmHg: continue current medication regimen and refill as prescribed 4, 5
- If BP 130-159/85-99 mmHg: confirm with out-of-office measurements (home BP monitoring or ambulatory BP monitoring) to rule out white coat hypertension 4
- If BP ≥160/100 mmHg: confirm within days to weeks and adjust therapy accordingly 4
First-Line Antihypertensive Therapy
If initiating or adjusting therapy, first-line options include: 5
- Thiazide or thiazide-like diuretic (hydrochlorothiazide or chlorthalidone) 5
- ACE inhibitor or ARB (enalapril or candesartan) 5
- Calcium channel blocker (amlodipine) 5
Target Blood Pressure Goals
Medication Considerations with Peripheral Arterial Disease
Beta-blockers are NOT contraindicated in patients with peripheral arterial disease and do not worsen claudication symptoms or impair functional status 4
ACE inhibitors or ARBs are particularly beneficial in patients with PAD to reduce cardiovascular events 4
Critical Pitfall to Avoid
Do not assume this is simply a traumatic toe fracture without considering alternative diagnoses in a patient with hypertension. While the history of acute trauma makes fracture most likely, sudden unilateral foot swelling with warmth and erythema in a patient with long-standing diabetes or neuropathy could represent acute Charcot neuroarthropathy, which requires immediate non-weight-bearing immobilization and urgent multidisciplinary referral 6. However, the clear traumatic mechanism (falling off chair with all weight on toe) and 1-day duration make simple fracture the most probable diagnosis 1, 2.
Follow-Up Plan
- Re-evaluate toe fracture in 1 week to assess healing and alignment 3
- Blood pressure recheck in 2-4 weeks if adjustments made, or per routine schedule if stable 4, 5
- Reinforce lifestyle modifications: weight loss, dietary sodium reduction (<2.3g/day), potassium supplementation, physical activity, and limited alcohol consumption 5