What is the appropriate management for an adult patient with no significant medical history presenting with a right great toe fracture?

Management of Right Great Toe Fracture

For an adult with a right great toe fracture, treat with a short leg walking boot or cast with toe plate for 2-3 weeks, followed by a rigid-sole shoe for an additional 3-4 weeks, with immediate orthopedic referral if the fracture is unstable, displaced, involves >25% of the joint surface, or is open. 1, 2

Immediate Assessment and Imaging

• Obtain anteroposterior and oblique radiographs to identify the fracture pattern, assess displacement, and evaluate for intra-articular involvement 1, 3
• Assess for point tenderness at the fracture site and pain with gentle axial loading of the digit 1
• Evaluate neurovascular status and soft tissue integrity to identify any circulatory compromise or open wounds 1

Indications for Urgent Orthopedic Referral

Refer immediately if any of the following are present:

• Circulatory compromise or significant soft tissue injury 1
• Open fractures or fracture-dislocations 1
• Displaced intra-articular fractures 1
• Unstable fractures or those involving more than 25% of the joint surface 1
• Any fracture requiring surgical stabilization 1, 2

Conservative Management for Stable, Nondisplaced Fractures

Initial immobilization (2-3 weeks):

• Apply a short leg walking boot or cast with toe plate to limit joint movement 2
• Allow weight-bearing as tolerated based on pain level 3, 2
• Provide adequate analgesia with acetaminophen and NSAIDs for pain control 3

Transition phase (3-4 weeks):

• Progress to a rigid-sole shoe after initial immobilization period 2
• Continue weight-bearing as tolerated with gradual increase in activity 2
• Total treatment duration is typically 5-7 weeks for complete healing 2

Management of Displaced Great Toe Fractures

• Displaced fractures of the first toe often require orthopedic referral for reduction and stabilization to prevent malunion and preserve weight-bearing function 1
• Closed reduction may be attempted for minimally displaced fractures, followed by immobilization in a boot or cast 1, 2
• Post-reduction radiographs are mandatory to confirm adequate alignment 3

Critical Pitfalls to Avoid

• Do not treat great toe fractures with simple buddy taping alone, as the great toe plays a critical role in weight-bearing and gait mechanics, requiring more rigid immobilization than lesser toes 1, 2
• Do not miss intra-articular involvement, as these fractures have higher rates of post-traumatic arthritis and may require surgical fixation 1, 3
• Do not overlook sesamoid fractures, which can present as great toe pain and require prolonged conservative management (2-6 months) or surgical intervention if conservative treatment fails 4
• Do not discharge without clear return precautions: patients should return immediately for worsening pain, numbness, color changes, or inability to bear weight 3

Follow-Up and Complications

• Schedule follow-up at 2 weeks to assess healing and adjust immobilization as needed 2
• Repeat radiographs at 4-6 weeks to confirm fracture union 3
• Monitor for complications including malunion, nonunion, post-traumatic arthritis, and stiffness 3
• Progressive physical therapy may be needed after immobilization to restore range of motion and strength 3