Do fractures of the fifth metatarsal or distal phalanx (pinky toe) require closed reduction or casting?

Do Pinky Toe Fractures Need to Be Set?

Most pinky toe fractures do NOT require formal closed reduction or casting and can be managed conservatively with buddy taping and immediate mobilization, except for specific high-risk fracture patterns that require more aggressive treatment.

Treatment Algorithm Based on Fracture Location and Pattern

Distal Phalanx (Toe) Fractures

• Conservative management is the standard approach for base fractures of the fifth proximal phalanx using buddy taping to the fourth digit with immediate mobilization 1.
• A prospective study of 53 consecutive patients demonstrated high overall satisfaction with this approach, with all but one patient regaining full flexion and only two patients having extension deficits 1.
• No formal reduction or casting is needed for most toe fractures, as functional outcomes prioritize mobility over exact anatomical reduction 1.
• Malrotation requiring corrective surgery is rare (occurred in 0 of 53 cases in the study) 1.

Fifth Metatarsal Fractures (Requires More Nuanced Approach)

Avulsion Fractures of the Base (Tuberosity)

• Immobilization in a short leg weightbearing cast for 4 weeks is preferred for avulsion fractures 2.
• If symptoms persist at 4 weeks, extend immobilization for an additional 1-3 weeks 2.
• A randomized controlled trial showed that symptomatic treatment with double elasticated bandage was non-inferior to cast immobilization at 4 weeks and 6 months for these fractures 3.
• Surgical intervention is indicated only if displaced >2 mm or involving >30% of the joint, treated with open reduction and tension-band wiring or screw fixation 4.

Jones Fractures (Metaphyseal-Diaphyseal Junction)

• These require more aggressive treatment with a short leg non-weightbearing cast for minimum 3-4 weeks, followed by 3 weeks in a weightbearing cast 2.
• Jones fractures have higher risk of delayed union and require individualized approach based on activity level 4.

Displaced Shaft and Neck Fractures

• Nondisplaced fractures and second-to-fourth metatarsal fractures with horizontal plane displacement can be treated conservatively with protected weightbearing in a cast shoe for 4-6 weeks 4.
• Grossly displaced fifth metatarsal shaft/neck fractures require open reduction and internal fixation with plate fixation (2.0-2.4 mm interlocking plates preferred) to restore anatomical structure 5.
• Long spiral fractures may be fixed with screws, while transverse or subcapital fractures can use percutaneous medullary wiring with two Kirschner wires 5.

Key Clinical Pitfalls to Avoid

• Do not immobilize simple toe fractures - this decreases mobility without improving outcomes 1.
• Do not restrict finger motion during any fracture treatment as this increases stiffness risk 6, 7.
• Avoid prolonged immobilization beyond necessary timeframes - complications occur in approximately 14.7% of cases with extended immobilization 6.
• Do not miss Jones fractures - these transverse metaphyseal-diaphyseal junction fractures require different management than simple avulsion fractures 4, 2.

Post-Treatment Management

• Immediate mobilization with buddy taping for distal phalanx fractures allows full return to function 1.
• For metatarsal fractures requiring immobilization, transition to weightbearing as tolerated in stable orthosis or cast shoe after initial treatment period 5.
• Reevaluate any patient with unremitting pain during follow-up, as this may indicate complications requiring intervention 6.