Management of Great Toe Fractures
For a fractured great toe, obtain plain radiographs (anteroposterior, lateral, and oblique views) to confirm the diagnosis, then treat stable, nondisplaced fractures with a short leg walking boot or rigid-sole shoe for 2-3 weeks followed by a rigid-sole shoe for an additional 3-4 weeks, while referring displaced fractures, fractures involving >25% of the joint surface, or unstable fractures to orthopedics. 1, 2
Initial Diagnostic Approach
Imaging Requirements
- Plain radiographs are the initial imaging study of choice for suspected great toe fractures, including anteroposterior, lateral, and oblique views 3
- The Ottawa foot rules do not specifically address toe fractures, but radiographs should be obtained when a toe fracture is clinically suspected based on point tenderness at the fracture site or pain with gentle axial loading 3, 1
- Weight-bearing views may be helpful for evaluating associated injuries but are not mandatory for isolated toe fractures 4
Clinical Assessment
- Examine for point tenderness at the fracture site and pain with gentle axial loading of the digit 1
- Check for signs requiring immediate referral: circulatory compromise, blue/purple/pale appearance of the toe, open fractures, or significant soft tissue injury 5, 1
- Assess for fracture displacement, intra-articular involvement, and stability 1, 2
Treatment Algorithm
Indications for Orthopedic Referral
- Circulatory compromise or vascular injury
- Open fractures
- Significant soft tissue injury
- Fracture-dislocations
- Displaced intra-articular fractures
- Fractures involving >25% of the joint surface
- Unstable fractures requiring surgical stabilization
- Displaced fractures that cannot be adequately reduced
Conservative Management (Stable, Nondisplaced Fractures)
Initial immobilization (2-3 weeks): 2
- Short leg walking boot with toe plate, OR
- Cast with toe plate, OR
- Rigid-sole shoe
Subsequent immobilization (additional 3-4 weeks): 2
- Transition to rigid-sole shoe
- Progressive weight-bearing as tolerated based on pain level 4
Total treatment duration: 5-7 weeks 2
Buddy Taping Considerations
- While buddy taping is commonly used for lesser toe fractures, great toe fractures typically require more rigid immobilization due to the toe's critical role in weight-bearing 1, 4, 6
- If buddy taping is used as an adjunct, ensure proper technique: clean and dry both toes, apply non-elastic adhesive tape firmly but not tight enough to compromise circulation, and check capillary refill after application 5
Critical Pitfalls to Avoid
Underestimating Great Toe Importance
- The great toe bears significant weight during gait and push-off, making inadequate treatment more likely to result in long-term pain and disability compared to lesser toe fractures 6
- Injuries to the hallux can result in long-term dysfunction if not properly diagnosed and treated 6
Missing Associated Injuries
- Evaluate for sesamoid fractures, which may accompany great toe trauma and require specific management 6
- Consider turf toe (plantar plate disruption) if there is a history of hyperextension injury, which may require weight-bearing radiographs with sesamoid axial views 3
Inadequate Immobilization
- Rigid-sole shoes or boots are essential—simple buddy taping alone is insufficient for great toe fractures unlike lesser toe fractures 1, 4, 2
- Ensure patients understand the importance of limiting joint movement during the healing period 1
Follow-Up and Complications
Monitoring
- Reassess at 2-3 weeks to evaluate healing and transition immobilization as appropriate 2
- Total immobilization typically ranges from 4-7 weeks depending on fracture severity and patient symptoms 4, 2