How should a fracture of the proximal phalanx of a toe be managed?

Management of Proximal Phalanx Fractures of the Toe

Most proximal phalanx fractures of the toe should be managed conservatively with buddy taping and protected weight-bearing, reserving surgery only for significantly displaced or unstable fractures that cannot maintain alignment with non-operative treatment. 1

Initial Assessment and Classification

The primary goal is achieving fracture healing in acceptable alignment while maintaining tendon gliding motion. 1 Determine fracture stability based on:

• Displacement: Fractures with minimal displacement (<2-3mm) are typically stable 1
• Angulation: Assess for rotational or angular deformity
• Intra-articular involvement: Fractures extending into the metatarsophalangeal or interphalangeal joints carry higher complication risk 2

Non-Operative Management (First-Line for Stable Fractures)

Stable fractures can be successfully treated non-operatively. 1 This approach includes:

• Buddy taping to the adjacent toe for 3-6 weeks 1
• Protected weight-bearing in a stiff-soled shoe or walking boot
• Early mobilization once pain permits to prevent stiffness 1, 3
• Dynamic splinting may be considered for displaced fractures that maintain reduction, allowing simultaneous bone healing and motion recovery 3

A study of 48 displaced proximal phalangeal fractures (hand) treated with dynamic splinting achieved fracture consolidation and full active motion in 92% of patients by 6 weeks. 3 While this study focused on hand fractures, the principles of protected mobilization apply to toe fractures.

Operative Management (Reserved for Unstable Fractures)

Unstable injuries benefit from surgery, but surgical intervention carries significant complication risks. 1, 2 Consider surgery only when:

• Fracture displacement cannot be maintained with closed reduction
• Significant intra-articular step-off (>2mm) exists
• Rotational deformity is present
• Open fracture requires debridement

Critical Caveat About Surgical Complications

Surgical fixation of proximal phalanx toe fractures has a notably high complication rate. A pediatric series of 10 intra-articular proximal phalanx fractures of the great toe showed 60% experienced significant complications including: postoperative redisplacement requiring revision, painful nonunion, refracture, posttraumatic arthritis requiring fusion, avascular necrosis, and K-wire migration. 2 Despite these complications, most patients were asymptomatic at final follow-up. 2

Surgical Technique When Necessary

• Minimize soft tissue dissection to reduce scarring and preserve tendon gliding 1
• K-wire fixation is most commonly used 2
• Headless compression screws may be considered for larger fragments 4
• The overriding goal is restoring anatomy with enough stability to allow early active motion 1

Common Pitfalls to Avoid

• Over-aggressive surgical intervention: The high complication rate of surgery (60% in one series) should make you cautious about operative management 2
• Excessive tension during reduction: Can cause avulsion fractures at soft tissue attachment sites 5
• Prolonged immobilization: Leads to stiffness; early protected motion is preferable once stability is achieved 1, 3
• Missing intra-articular extension: These fractures are particularly difficult to manage and have worse outcomes 2

Follow-Up Expectations

• Radiographic union: Typically occurs at 6-8 weeks 3, 2
• Return to full activity: Most patients achieve this by 6-12 weeks with non-operative management 3
• Monitor for complications: Nonunion, malunion, stiffness, and post-traumatic arthritis 4, 2