What is the recommended first‑line treatment for an isolated proximal phalanx fracture of the great toe in an otherwise healthy adult?

Treatment of Isolated Proximal Phalanx Fracture of the Great Toe

For an isolated proximal phalanx fracture of the great toe in a healthy adult, buddy taping to the adjacent toe with immediate mobilization is the recommended first-line treatment for stable fractures, while unstable fractures require surgical fixation with Kirschner wires. 1, 2

Initial Assessment and Classification

The critical first step is determining fracture stability through clinical examination and radiographs. Assess for:

• Fracture angulation: Acceptable if ≤25° in sagittal plane and ≤10° in coronal plane after closed reduction 2
• Rotational deformity: Any uncorrectable rotation mandates surgical intervention 2
• Displacement: Stable, non-displaced fractures can be managed conservatively 1, 3

Treatment Algorithm

For Stable Fractures (Non-displaced or Acceptable Alignment)

Buddy taping with immediate mobilization is the definitive treatment:

• Tape the injured great toe to the second toe for support 4
• Begin immediate weight-bearing and mobilization—do not immobilize 2, 4
• No rigid splinting or casting is necessary for stable fractures 3
• This approach achieves excellent functional outcomes with minimal pain and full range of motion in most patients 2, 4

For Unstable Fractures (Displaced, Angulated, or Rotated)

Surgical fixation is required:

• Perform open reduction with 1.0 mm percutaneous intramedullary Kirschner wire fixation 3
• The goal is to restore anatomy and provide enough stability for early active motion 1
• Minimize surgical dissection to reduce soft tissue scarring that impedes tendon gliding 1
• This method provides reliable long-term results with excellent total active motion scores 3

Pain Management

• Administer regular paracetamol throughout the treatment period as the foundation of analgesia 5, 6
• Use opioids cautiously if needed, particularly avoiding codeine which causes constipation and cognitive dysfunction 6
• Avoid NSAIDs entirely if any degree of renal dysfunction exists 5, 6

Expected Outcomes and Follow-up

Conservative treatment with buddy taping typically results in:

• Mean total active motion of 253° (SD 20) 2
• Minimal residual pain at 7 weeks mean follow-up 2
• Full flexion recovery in nearly all patients 4
• High patient satisfaction with functional outcomes 4

Surgical fixation with Kirschner wires achieves:

• Perfect total active motion scores (≥150° for great toe) in the majority of cases 3
• Equivalent grip strength compared to uninjured digits 3
• Excellent long-term results extending up to 9 years 3

Critical Pitfalls to Avoid

• Do not immobilize stable fractures—this leads to stiffness and prolonged recovery 2, 4
• Do not accept rotational deformity—even minor malrotation requires surgical correction 2
• Do not over-dissect during surgery—excessive soft tissue disruption causes tendon adhesions and poor functional outcomes 1
• Monitor radiographically for nonunion, though this complication is rare with appropriate treatment 7, 3