Management of Comminuted Fracture of Proximal Phalanx of Great Toe
For a comminuted fracture of the proximal phalanx of the great toe, conservative management with buddy taping to the second toe and protected weight-bearing in a rigid-soled shoe for 4-6 weeks is the recommended approach, as most toe fractures do not require aggressive surgical intervention.
Initial Assessment and Pain Control
- Administer regular paracetamol as first-line analgesia immediately, and add opioids cautiously only if paracetamol proves insufficient, using reduced doses if any renal dysfunction is present 1
- Avoid NSAIDs until renal function is confirmed, as approximately 40% of trauma patients have some degree of renal impairment 2
- Document pain scores before and after analgesia to guide ongoing management 1
Conservative Management Protocol
The vast majority of toe fractures, including comminuted fractures of the proximal phalanx, heal successfully with non-operative treatment. 3
- Buddy tape the great toe to the second toe for stability and pain relief 3
- Prescribe a rigid-soled shoe or walking boot to protect the fracture and allow protected weight-bearing 3
- Continue immobilization for 4-6 weeks, similar to protocols for other proximal fractures 2
- Initiate gentle range of motion exercises after 4 weeks if pain allows 4
When to Consider Surgical Intervention
Surgical treatment should be reserved for specific indications:
- Intra-articular involvement with significant displacement requiring anatomic reduction to prevent post-traumatic arthritis 4
- Open fractures with nail bed injury or laceration proximal to the nail fold, which signal likely open fracture requiring irrigation, debridement, and stabilization 3, 5
- Failure to maintain acceptable alignment with conservative measures 6
For surgical cases, options include:
- K-wire fixation for simple stabilization 3, 5
- External fixation systems (such as Ichi-Fixator) for comminuted intra-articular fractures requiring distraction 4
- Suture-only stabilization for open physeal fractures in pediatric patients 5
Critical Pitfalls to Avoid
- Do not miss open fractures: Any bleeding at the nail base, laceration proximal to the nail fold, or displaced physeal fracture in a "stubbed toe" mechanism indicates a likely open fracture requiring urgent surgical treatment 3, 5
- Do not delay pain assessment: Toe fractures can be extremely painful, and inadequate analgesia increases morbidity 1, 7
- Do not use standard opioid dosing without considering renal function, as many trauma patients have unrecognized renal impairment 2
- Do not overlook the need for protected weight-bearing: Allowing full unprotected weight-bearing too early can lead to displacement and delayed union 1