What is the appropriate evaluation and work‑up for a patient with toe pain when a fracture is suspected?

Evaluation and Work-Up for Suspected Toe Fracture

For suspected toe fractures, obtain anteroposterior and oblique radiographs of the foot to confirm or rule out the fracture, as this is the standard initial imaging approach with excellent diagnostic accuracy. 1, 2

Initial Clinical Assessment

Key History Elements

• Mechanism of injury: Most toe fractures result from crushing injuries or axial forces (stubbing), with joint hyperextension and stress fractures being less common 2
• Timing and onset: Acute trauma versus gradual onset helps differentiate acute fractures from stress injuries 3
• Weight-bearing ability: Varies based on fracture extent and pain tolerance, but inability to ambulate suggests more significant injury 3

Physical Examination Findings

• Point tenderness at the fracture site is the hallmark finding 2
• Pain with gentle axial loading of the affected digit confirms bony injury 2
• Swelling and ecchymosis of the affected area are typical 3
• Assess for open wounds or skin compromise requiring urgent intervention 4

Imaging Protocol

Standard Radiographic Views

Obtain anteroposterior and oblique radiographs as the initial imaging study - these views are most useful for identifying fractures, determining displacement, and evaluating adjacent structures 1, 2, 3

• Weight-bearing radiographs should be obtained when possible to assess functional alignment 3
• Lateral views can be added for complete evaluation 3
• The Ottawa foot rules do not directly address forefoot and toe injuries, so clinical suspicion should guide imaging decisions 1

Advanced Imaging (Rarely Needed)

• CT is not routinely indicated for simple toe fractures and is reserved for complex midfoot or hindfoot injuries 1
• MRI is not used as a first-line study for acute toe trauma 1
• Ultrasound has limited utility with only 90.9% sensitivity compared to radiography's superior performance 1

Immediate Referral Indications

Refer urgently to orthopedics for any of the following 2:

• Circulatory compromise
• Open fractures
• Significant soft tissue injury
• Fracture-dislocations
• Displaced intra-articular fractures
• Great toe (first toe) fractures that are unstable or involve >25% of the joint surface
• Most pediatric physeal fractures (except selected nondisplaced Salter-Harris types I and II) 2

Common Pitfalls to Avoid

• Do not dismiss great toe injuries - these require closer attention due to their critical role in weight-bearing and gait, with lower thresholds for referral 2, 3
• Do not rely on weight-bearing ability alone - patients may still ambulate with certain fractures depending on pain tolerance 3
• Do not overlook associated injuries - always examine adjacent digits and the midfoot, as Lisfranc injuries can be missed 1, 3
• Do not skip radiographs based on clinical examination alone - imaging is necessary to document fractures and guide treatment 1, 2