What is the recommended management for a minimally displaced intra‑articular proximal phalanx fracture of the great toe?

Management of Minimally Displaced Intra-articular Proximal Phalanx Fracture of the Great Toe

For minimally displaced intra-articular proximal phalanx fractures of the great toe, I recommend conservative management with rigid immobilization using a hard-soled shoe or walking boot for 4-6 weeks, combined with close radiographic surveillance at 10-14 days and 4-6 weeks to detect displacement, given the 30-50% risk of subsequent displacement that may necessitate surgical intervention. 1

Initial Assessment and Risk Stratification

The critical decision point is determining true stability, as even "minimally displaced" intra-articular fractures carry substantial displacement risk:

• Displacement risk is 30-50% with conservative management, making close follow-up mandatory rather than optional 1, 2
• Obtain initial radiographs in multiple views to confirm minimal displacement (typically <2mm articular step-off) 2
• Document the exact location: proximal phalangeal base fractures are most common and have higher complication rates 3

Conservative Management Protocol (First-Line for Truly Minimally Displaced Fractures)

Immobilization approach:

• Use rigid immobilization rather than removable splints, as rigid immobilization maintains reduction more effectively 4
• A hard-soled shoe or walking boot provides adequate stability while allowing weight-bearing as tolerated 1
• Duration: 4-6 weeks of immobilization 2

Mandatory radiographic surveillance:

• First follow-up at 10-14 days to catch early displacement 2
• Second follow-up at 4-6 weeks to confirm healing 2
• Any displacement >2mm or articular incongruity warrants surgical consideration 1

When to Abandon Conservative Management

Indications for surgical intervention:

• Any displacement detected on follow-up radiographs (occurs in 30-50% of cases) 1, 2
• Initial displacement >2-3mm despite appearing "minimal" 3
• Inability to maintain reduction with immobilization alone 1
• Open fractures (common with "stubbed toe" mechanism with nail bed injury) 5

Surgical technique if needed:

• K-wire fixation is most commonly employed for great toe proximal phalanx fractures 3
• Open reduction is frequently necessary (required in 9 of 10 cases in one series) 3
• Be prepared for complications: surgical intervention carries a 60% complication rate including redisplacement, nonunion, avascular necrosis, and posttraumatic arthritis 3

Critical Pitfalls to Avoid

The "minimally displaced" trap:

• Do not assume minimal displacement equals stability—30-50% will displace further 1, 2
• Failure to obtain adequate follow-up radiographs is the most common error leading to malunion 1

Neurologic complications:

• Even nondisplaced fractures can cause nerve irritation or entrapment 1
• If persistent neurologic pain develops after apparent fracture healing, obtain EMG, nerve conduction studies, and MRI 1
• Refer to podiatric foot and ankle surgery if neuroma develops 1

Surgical overtreatment risks:

• While surgical fixation reduces displacement risk, the complication rate is substantial (60% in pediatric series) 3
• Most patients ultimately return to full activity regardless of complications, suggesting conservative management deserves first attempt in truly minimally displaced fractures 3

Special Populations

Pediatric patients (physeal involvement):

• Four of seven proximal phalangeal base fractures in one series occurred through open physes 3
• Higher vigilance needed as these may appear minimally displaced but have greater instability 3
• Stubbed toe with nail bed bleeding suggests open fracture requiring urgent irrigation and antibiotics 5

Athletes:

• Consider earlier surgical intervention to allow rigid fixation and immediate range of motion for faster return to sport 6
• Percutaneous headless compression screws may be preferred over K-wires in high-demand athletes 6

Expected Outcomes

With appropriate conservative management and surveillance:

• Fracture healing occurs at mean 7-9 weeks 3
• Most patients return to full activity without limitation 3
• Transfer lesions or metatarsalgia may develop if weight-bearing pattern is altered during healing 2