Management of a Bruised Second Toe with Suspected Fracture
If you suspect a second toe fracture, obtain plain radiographs (anteroposterior and oblique views) to confirm the diagnosis, then treat with buddy taping to the third toe and a rigid-sole shoe for 4-6 weeks. 1, 2, 3
Initial Assessment
Immediate Evaluation
- Check for vascular compromise immediately by assessing the toe color—if the toe appears blue, purple, or pale, activate emergency services as this indicates poor perfusion requiring urgent intervention. 1
- Examine for open wounds that would require coverage with a clean dressing to reduce contamination and infection risk. 1
- Assess point tenderness at the fracture site and pain with gentle axial loading of the digit, which are the most common clinical findings in toe fractures. 2
When to Image
- Radiographs are indicated when a toe fracture is suspected to document or rule out fracture, as toe injuries are not directly addressed by the Ottawa foot rules. 1
- Order anteroposterior and oblique radiographs as these views are most useful for identifying fractures, determining displacement, and evaluating adjacent structures. 2, 4
Treatment Algorithm
For Stable, Nondisplaced Fractures (Most Common)
- Buddy tape the second toe to the third toe with gauze or padding between the toes to prevent skin maceration. 2, 3, 4
- Provide a rigid-sole shoe or hard-soled shoe to limit joint movement and protect the fracture during weight-bearing. 2, 3, 4
- Duration: 4-6 weeks of buddy taping and rigid footwear. 3, 4
- Weight-bearing is permitted as tolerated based on pain level. 4
For Displaced Fractures of Lesser Toes
- Perform closed reduction followed by buddy taping and rigid-sole shoe. 2
- Same immobilization duration of 4-6 weeks applies. 3, 4
Pain Management
- Apply ice wrapped in a damp cloth for 20-30 minutes, 3-4 times daily to decrease acute pain and swelling—never place ice directly on skin. 1
- Provide scheduled acetaminophen as first-line analgesia unless contraindicated. 5
- Consider opioids cautiously if pain is severe, avoiding NSAIDs if renal function is unknown. 5
- Note that proper immobilization provides superior pain relief compared to medications alone. 5
When to Refer to Orthopedics
Absolute Indications for Referral
- Circulatory compromise (blue, purple, or pale toe). 1, 2
- Open fractures with skin disruption. 1, 2
- Significant soft tissue injury beyond simple bruising. 2
- Fracture-dislocations requiring reduction and stabilization. 2
- Displaced intra-articular fractures that may compromise joint function. 2
Special Considerations
- Most children with physeal (growth plate) fractures should be referred, except for selected nondisplaced Salter-Harris types I and II fractures which can be managed by primary care. 2
- Patients with diabetes and neuropathy require special attention to offloading to prevent complications. 5
Common Pitfalls to Avoid
- Do not apply compression wraps too tightly as this can compromise circulation to the toe. 1
- Do not immobilize for prolonged periods beyond 6 weeks as this leads to stiffness and muscle atrophy requiring rehabilitation. 5
- Do not miss open wounds that require immediate coverage and possible antibiotic prophylaxis. 1
- Do not assume all toe fractures are benign—always assess neurovascular status and consider referral criteria. 1, 2