Acute Management of a Crushed Hallux (Great Toe) Injury
Begin with weight-bearing radiographs in three views (AP, lateral, and sesamoid axial) as the mandatory first-line imaging study, and maintain a high index of suspicion for open fracture if there is any nail bed injury or bleeding present. 1, 2
Initial Clinical Assessment
Critical Red Flags to Identify Immediately
- Any nail bed injury or bleeding from the nail fold indicates a potential open physeal fracture (analogous to Seymour fracture), which requires urgent surgical management with antibiotics to prevent osteomyelitis, physeal arrest, and chronic infection 3, 4
- These injuries are frequently missed by initial providers (40% in one series), leading to delayed diagnosis and worse outcomes 4
- In children, physeal fractures of the distal phalanx with nail bed involvement are open fractures until proven otherwise 3, 4
Physical Examination Priorities
- Assess for nail bed disruption, subungual hematoma, or bleeding from the nail fold 3, 4
- Evaluate for gross deformity suggesting dislocation or displaced fracture 5, 6
- Check neurovascular status distally 5
- Palpate the metatarsophalangeal (MTP) joint for instability or plantar plate injury 1, 5
Imaging Algorithm
First-Line Imaging (Always Required)
- Obtain weight-bearing AP, lateral, and sesamoid axial views of the foot 1, 2
- Add bilateral comparison views of the contralateral foot to identify subtle malalignment 2, 7
- Non-weight-bearing films are unreliable and should be avoided when the patient can bear weight 2, 7
Advanced Imaging (When Indicated)
Proceed to CT if:
- High-energy crush mechanism or polytrauma is present 2, 7
- Complex fracture patterns require preoperative planning 2, 7
- Patient cannot bear weight for radiographs 2, 7
Proceed to MRI if:
- Radiographs are negative but clinical suspicion remains high for soft tissue injury 2, 7
- Suspected plantar plate disruption, sesamoid injury, or turf toe mechanism 1, 5
- MRI is the preferred modality for evaluating capsuloligamentous complex injuries 1
Immediate Management Based on Findings
If Open Fracture Suspected (Nail Bed Injury Present)
- Start prophylactic antibiotics immediately before any surgical intervention 7, 3
- Urgent surgical consultation for irrigation, debridement, nail bed repair, and fracture stabilization 3, 4
- Suture-only stabilization is a reliable alternative to pin fixation for pediatric physeal fractures 4
- Mean time to surgery should be within 2-3 days to minimize infection risk 4
If Closed Fracture Without Displacement
- Buddy taping to adjacent toe 5, 6
- Hard-soled shoe or walking boot for immobilization 5, 6
- Ice, elevation, and analgesia 7, 5
- Weight-bearing as tolerated 5, 6
If MTP Joint Injury or Turf Toe Suspected
- Obtain weight-bearing radiographs with sesamoid axial views to assess for plantar plate disruption 1
- Consider fluoroscopy to evaluate sesamoid tracking with forced dorsiflexion if instability suspected 1
- Grade 1-2 injuries: conservative management with taping, stiff-soled shoes, and activity modification 5, 6
- Grade 3 injuries or traumatic hallux valgus: may require surgical repair, particularly in athletes 8
Critical Pitfalls to Avoid
- Never dismiss a toe injury with nail bed involvement as "just a stubbed toe"—these are open fractures requiring antibiotics and surgical management 3, 4
- Do not rely on non-weight-bearing radiographs alone, as they miss significant injuries 2, 7
- Do not delay treatment of open physeal fractures beyond 2-3 days, as this increases infection and complication rates 4
- In diabetic patients with neuropathy, image more liberally as they may bear weight despite significant fractures 2, 7
- Failure to recognize and treat MTP joint injuries can lead to chronic pain, deformity, and inability to return to sports (25% of athletes with traumatic hallux valgus cannot return to play) 8