What is the appropriate management for a patient with a broken toe, especially considering potential complications and pre-existing medical conditions like diabetes?

Management of a Broken Toe

For most patients with a broken toe, treatment consists of buddy taping to an adjacent toe and wearing a rigid-sole shoe for 4-6 weeks, with immediate weight-bearing as tolerated; however, patients with diabetes require heightened vigilance for complications and may need specialized footwear or offloading devices. 1, 2

Initial Evaluation and Imaging

When a toe fracture is suspected, obtain anteroposterior and oblique radiographs to identify the fracture, assess displacement, and evaluate adjacent structures. 1 Weight-bearing views should be included when possible to better assess alignment. 3, 2

Important caveat: Do not apply the Ottawa rules in patients with diabetic neuropathy, as pain perception may be diminished and patients may ambulate despite significant fractures. 3 These patients should be radiographed regardless of clinical findings.

Standard Management for Non-Diabetic Patients

Lesser Toe Fractures (Toes 2-5)

• Stable, nondisplaced fractures: Buddy tape to adjacent toe and use rigid-sole shoe for 4-6 weeks 1, 2, 4
• Displaced fractures: Perform closed reduction, then buddy tape and rigid-sole shoe 1
• Weight-bearing is permitted as tolerated based on pain level 2

Great Toe (Hallux) Fractures

The great toe requires more aggressive management due to its critical role in weight-bearing. 2, 5

• Nondisplaced fractures: Short leg walking boot or cast with toe plate for 2-3 weeks, followed by rigid-sole shoe for additional 3-4 weeks 4
• Displaced fractures or those involving >25% of joint surface: Require orthopedic referral for stabilization 1
• Unstable fractures: Require orthopedic referral 1

Critical Management Considerations for Diabetic Patients

Patients with diabetes and a broken toe face substantially higher risks and require modified management protocols. 3

Key Risk Factors in Diabetic Patients

• Loss of protective sensation (LOPS) from neuropathy prevents normal pain response 3
• Peripheral arterial disease (PAD) impairs healing 3
• Higher risk of infection, including osteomyelitis 3
• Risk of Charcot neuroarthropathy if fracture not properly immobilized 3

Enhanced Assessment Required

Perform comprehensive vascular assessment including:

• Palpation of pedal pulses 3
• Ankle-brachial index (ABI) and toe pressures 3
• If ABI <0.5 or ankle pressure <50 mmHg, consider urgent vascular imaging and revascularization 3

Assess for neuropathy using 10-g monofilament testing plus at least one additional test (pinprick, vibration with 128-Hz tuning fork, or ankle reflexes). 3

Modified Treatment Protocol for Diabetic Patients

For diabetic patients with toe fractures and intact skin:

• Consider non-removable knee-high offloading device (total contact cast or irremovable walker) to prevent progression to Charcot neuroarthropathy 3
• If non-removable device contraindicated, use removable knee-high device worn at all times 3
• Custom therapeutic footwear may be required after initial healing to accommodate deformities and prevent ulceration 3

Critical warning: Patients with diabetes and neuropathy may continue walking on fractured toes without pain, leading to progressive deformity, Charcot arthropathy, or skin breakdown. 3

Infection Surveillance

Monitor closely for signs of infection, which may be subtle in diabetic patients:

• Look for at least two signs of inflammation: redness, warmth, induration, pain/tenderness, or purulent secretions 3
• Systemic signs (fever, elevated WBC) are often absent 3
• If infection develops, classify as mild (superficial), moderate (deeper), or severe (systemic sepsis) 3

For moderate or severe infections: Obtain urgent surgical consultation within 24-48 hours for debridement combined with antibiotics. 3

Osteomyelitis Risk

Assess for osteomyelitis if:

• Wound is longstanding or deep 3
• Bone is visible or palpable with sterile probe 3
• Plain radiographs suffice for initial screening 3

Indications for Urgent Orthopedic Referral

Refer immediately for:

• Open fractures 1
• Circulatory compromise 1
• Significant soft tissue injury 1
• Fracture-dislocations 1
• Displaced intra-articular fractures 1
• Great toe fractures that are unstable or involve >25% of joint surface 1
• Most physeal fractures in children (except selected nondisplaced Salter-Harris I and II) 1

Follow-Up and Complications

Monitor for common complications including:

• Malunion or nonunion 2, 6
• Post-traumatic arthritis 2
• Infection/osteomyelitis (especially in diabetic patients) 3, 6
• Compartment syndrome (rare but limb-threatening) 2

For diabetic patients: Life-long frequent foot examinations are warranted, as most with history of foot complications remain at high risk for future problems. 3