Treatment of 5th Toe Fractures
Most 5th toe fractures should be managed conservatively with buddy taping to the 4th toe, a rigid-soled shoe or walking boot, analgesia, and early mobilization as pain allows—surgery is rarely needed unless there is significant displacement, open fracture, or vascular compromise. 1
Immediate Assessment and Imaging
- Obtain radiographs when there is point tenderness at the base of the 5th metatarsal or inability to bear weight for four steps, following the Ottawa ankle rules to guide imaging decisions 1, 2
- Weight-bearing films can provide additional stability information when clinically appropriate 1
Initial Management
Pain Control
- Start with scheduled acetaminophen as first-line analgesia, adding opioids cautiously only if acetaminophen proves insufficient 1
- Apply ice with elevation to reduce swelling, but avoid direct ice-to-skin contact to prevent cold injury 1
Immobilization and Protection
- Buddy tape the 5th toe to the 4th toe with gauze padding between the toes to prevent skin maceration 1
- Provide a rigid-soled shoe or walking boot for protection and comfort 1
- Avoid tight compression wraps that could compromise circulation—this is a critical safety consideration 1
Indications for Urgent Orthopedic Referral
Refer immediately for:
- Circulatory compromise or vascular injury 1
- Open fractures requiring wound management 1
- Grossly displaced fractures with significant angulation or rotation (though this is uncommon in isolated toe fractures)
Rehabilitation and Mobilization
- Begin early mobilization and physical training as soon as pain allows to prevent stiffness and muscle atrophy 1
- Range-of-motion exercises should start within the first few days after injury 3
- Weight-bearing should be as tolerated—most patients can walk immediately with appropriate footwear 1
Special Considerations for Older Adults
For patients over 50 years with any fracture:
- Assess for fragility fracture risk factors and consider underlying osteoporosis 4
- Consider vitamin D supplementation (800 IU/day) with adequate calcium intake (1000-1200 mg/day) if risk factors are present 3, 4
Common Pitfalls to Avoid
- Do not immobilize for prolonged periods—this leads to stiffness and poor functional outcomes 3, 1
- Do not apply circumferential tight wrapping—this risks compartment syndrome or vascular compromise 1
- Avoid assuming all 5th ray fractures are the same—distinguish between toe (phalanx) fractures and 5th metatarsal base fractures (Jones fractures), as the latter require different management