What is the recommended treatment for a patient with a distal 5th toe fracture, considering potential underlying conditions such as diabetes?

Treatment of Distal 5th Toe Fractures

For a distal 5th toe fracture, treat 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

• Apply the Ottawa foot rules to determine if radiographs are needed: imaging is indicated if there is point tenderness at the base of the 5th metatarsal or inability to bear weight for four steps 1
• Obtain anteroposterior, lateral, and oblique radiographs when fracture is suspected 3
• Weight-bearing views can provide additional stability information when clinically appropriate 1

Immediate Management

Pain Control

• Provide multimodal analgesia starting with scheduled acetaminophen, adding opioids cautiously only if needed 1
• Apply ice and elevation to reduce swelling, avoiding direct ice-to-skin contact 1

Immobilization

• Buddy tape the 5th toe to the 4th toe for stability and comfort 2, 3
• Prescribe a rigid-sole shoe or hard-soled shoe for 4-6 weeks 2, 3
• Avoid tight compression wraps that could compromise circulation 1

Mobilization and Rehabilitation

• Begin range-of-motion exercises within the first few days after injury to prevent stiffness and muscle atrophy 1
• Avoid prolonged immobilization, as this leads to stiffness and poor functional outcomes 1, 4
• Weight-bearing should be as tolerated based on pain level 3

Follow-Up Protocol

• Routine follow-up radiographs are NOT necessary for stable, non-displaced toe fractures healing appropriately 4
• Repeat imaging should only be obtained if there is new trauma, increased pain, loss of range of motion, or neurovascular symptoms 4
• If initial radiographs are equivocal but clinical suspicion remains high, consider repeat films in 10-14 days 4
• Follow-up radiographs taken before 6-8 weeks do not appear to alter patient management 5

Indications for Orthopedic Referral

• Refer immediately for circulatory compromise or vascular injury 1
• Refer immediately for open fractures requiring wound management 1
• Consider referral for grossly displaced fractures (>3-4mm displacement or >10 degrees angulation) 6, 7

Special Considerations for Diabetic Patients

Critical Precautions

• Do not apply the Ottawa rules in patients with diabetic neuropathy, as pain perception may be diminished and patients may ambulate despite fracture 8
• Radiograph the foot if fracture is suspected in neurologically compromised patients, regardless of ability to bear weight 8

Footwear and Offloading

• Instruct diabetic patients never to walk barefoot, in socks only, or in thin-soled slippers 8
• Ensure properly fitting footwear to prevent ulceration 8
• The rigid-sole shoe must be in close contact with the entire foot to provide adequate immobilization 9
• Insoles should accommodate any foot deformity safely and provide pressure redistribution 9

Monitoring for Complications

• Monitor carefully for skin breakdown, as improperly fitted shoes can cause ulceration in up to 14% of cases in patients with sensory neuropathy 9
• Assess for signs of infection: erythema, warmth, tenderness, pain, induration, or purulent secretions 8
• Evaluate the affected limb for arterial ischemia and venous insufficiency 8
• Check pedal pulses and consider ankle-brachial index (ABI) if pulses are absent or diminished 8

Wound Care (if present)

• Provide appropriate wound dressings based on wound characteristics 8
• Consider multidisciplinary diabetic foot care team involvement for complex cases 8

Common Pitfalls to Avoid

• Do not use prolonged immobilization beyond what is necessary, as this increases stiffness and delays return to function 1, 4
• Do not routinely obtain follow-up radiographs unless clinically indicated, as this increases healthcare contacts without changing management 4, 5
• Ensure patient understanding of adherence importance, as inconsistent use of protective footwear can delay healing by a median of 3 months 9
• In diabetic patients, do not delay treatment while waiting for imaging if clinical suspicion is high 8

Nutritional Support for Older Adults

• For patients over 50 years with fracture risk factors, consider vitamin D supplementation (800 IU/day) with adequate calcium intake (1000-1200 mg/day) 1