Treatment of 5th Toe Fractures
Most 5th toe fractures should be treated conservatively with buddy taping to the 4th toe and a rigid-sole shoe for 4-6 weeks, with early mobilization as pain allows. 1, 2
Initial Assessment and Imaging
- Obtain anteroposterior and oblique radiographs to identify the fracture, assess displacement, and evaluate adjacent structures 1
- Apply the Ottawa ankle rules to determine imaging necessity: radiographs are required if there is point tenderness at the base of the 5th metatarsal or inability to bear weight for four steps 3, 4
- Weight-bearing radiographs provide additional information about fracture stability when clinically appropriate 3
Immediate Management
- Provide multimodal analgesia starting with scheduled acetaminophen, adding opioids cautiously if needed 4
- Apply buddy taping to the adjacent 4th toe to provide stability and limit motion 1, 5
- Prescribe a rigid-sole shoe or hard-soled shoe to restrict joint movement and facilitate protected weight-bearing 1, 2
- Ice and elevation can reduce swelling, but avoid direct ice-to-skin contact 4
Treatment Duration and Weight-Bearing
- Continue buddy taping and rigid-sole shoe for 4-6 weeks for most stable, nondisplaced fractures 1, 2
- Allow weight-bearing as tolerated based on pain level—most patients can bear weight immediately with appropriate footwear 2, 5
- Early functional therapy is superior to prolonged immobilization, leading to faster return to work and normal activities 6
Indications for Orthopedic Referral
Refer immediately for: 1
- Circulatory compromise or vascular injury
- Open fractures requiring wound management
- Significant soft tissue injury or compartment syndrome concerns
- Fracture-dislocations requiring reduction and stabilization
- Displaced intra-articular fractures involving joint surfaces
- Fractures of the great (1st) toe that are unstable or involve >25% of the joint surface
- Physeal fractures in children (except selected nondisplaced Salter-Harris I and II fractures) 1
Special Considerations
- Displaced fractures of lesser toes can be reduced by the primary care physician followed by buddy taping 1
- The 5th toe plays a minimal role in weight-bearing compared to the great toe, allowing for more conservative management 2
- Avoid tight compression wraps that could compromise circulation 4
- Early mobilization and physical training should begin as soon as pain allows to prevent stiffness and muscle atrophy 3, 4
Common Pitfalls
- Do not confuse 5th toe fractures with 5th metatarsal base fractures—the latter require different management strategies including potential non-weight-bearing and longer immobilization 5, 6
- Do not over-immobilize—prolonged casting leads to stiffness without improving outcomes for stable toe fractures 6
- Do not miss open fractures or neurovascular compromise which require urgent referral 1