Treatment of Comminuted Fracture of Distal Great Toe
For a comminuted fracture of the distal great toe, initial treatment consists of 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 active toe motion exercises to prevent stiffness. 1
Initial Assessment and Imaging
- Obtain anteroposterior, lateral, and oblique radiographs to confirm the diagnosis and assess fracture displacement 2
- Evaluate specifically for displacement >3mm or angulation >10°, as these parameters indicate need for surgical intervention 3
- Assess for open fracture indicators: bleeding at the nail base, laceration proximal to the nail fold, or visible bone displacement through the physis signal a likely open fracture requiring urgent surgical management 4, 5
Critical Pitfall to Avoid
Open physeal fractures of the great toe distal phalanx (Seymour fractures) are frequently missed by initial providers (40-60% in case series), leading to osteomyelitis, growth disturbances, and nail deformities. 4, 5 Any great toe "stubbing" injury with nail bed involvement should raise high suspicion for an open fracture.
Treatment Algorithm
For Non-Displaced or Minimally Displaced Fractures (<3mm, <10° angulation):
- Apply a short leg walking boot or cast with toe plate for 2-3 weeks 1
- Initiate active toe motion exercises immediately to prevent stiffness without adversely affecting adequately stabilized fractures 3
- Transition to a rigid-sole shoe for an additional 3-4 weeks 1
- Obtain radiographic follow-up at approximately 3 weeks and at time of immobilization removal 6
For Displaced or Comminuted Fractures (>3mm displacement or >10° angulation):
- Perform open reduction and internal fixation (ORIF) as recommended by the American Academy of Orthopaedic Surgeons for any fracture exceeding these displacement parameters 3
- Do not use removable splints for comminuted fractures, as these require rigid fixation 3
- For open fractures with nail bed injury, suture-only stabilization represents a simple, reliable alternative to pin fixation with no reported infections or physeal bars in recent case series 5
Post-Treatment Management
- Active finger and toe motion exercises should begin immediately after surgery to prevent stiffness 3
- Radiographic follow-up at 3 weeks post-injury and at time of immobilization removal to confirm adequate healing 6
- Monitor for immobilization-related complications including skin irritation and muscle atrophy, which occur in approximately 14.7% of cases 6, 7
Surgical Considerations for Open/Comminuted Fractures
When open fractures are identified, surgical treatment should occur within 2.6 days on average (range 0-6 days) to minimize infection risk 5. For truly comminuted fractures with compromised soft tissue, bilateral external fixation combined with limited internal fixation achieves 85.29% excellent-to-good outcomes with average union time of 16.3 weeks 8.
Weight-Bearing Status
Weight-bearing tolerance varies based on fracture stability and patient pain level 2. For stable, non-displaced fractures treated conservatively, progressive weight-bearing as tolerated in a walking boot is appropriate 1. For surgically treated displaced or comminuted fractures, weight-bearing restrictions should follow standard ORIF protocols until radiographic evidence of healing 3.