What is the emergency management of a severely comminuted fracture of the great toe that may require amputation?

Emergency Management of Severely Comminuted Great Toe Fracture with Potential Amputation

Immediate Hemorrhage Control and Stabilization

Apply direct manual compression with a pressure dressing immediately to control any active bleeding from the fracture site. 1

• If life-threatening hemorrhage cannot be controlled with direct pressure alone, apply a tourniquet as an adjunct measure. 2
• Immobilize the extremity immediately to prevent further soft tissue and neurovascular injury. 2
• Assess the patient's overall hemodynamic status, as this will determine whether you proceed with definitive management or damage-control measures. 1

Antibiotic Prophylaxis

Initiate intravenous antibiotic prophylaxis immediately upon presentation if the fracture is open or there is significant soft tissue compromise. 1, 2

• Use cefazolin as first-line therapy, or clindamycin if the patient has a beta-lactam allergy. 2
• Early antibiotic administration significantly reduces infection rates in open fractures. 1, 2
• Do not exceed 48-72 hours of prophylaxis unless documented infection develops. 1

Wound Management for Open Fractures

• Irrigate the wound with simple saline solution only—avoid antiseptics or soap additives, as they provide no benefit and may cause harm. 2
• Wrap the wound in a sterile wet dressing to prevent desiccation and contamination. 2
• Never place anything directly into the wound that could cause further tissue damage. 2

Radiographic Evaluation

Obtain anteroposterior, lateral, and 45-degree oblique radiographs of the foot to assess fracture displacement, comminution, and joint involvement. 3, 4

• These three standard projections are essential to avoid missing complex derangement of the foot's arc geometry. 5
• Evaluate for displacement exceeding 2-3mm, articular step-off, and the extent of comminution. 3

Decision Algorithm: Limb Salvage vs. Primary Amputation

Absolute Indications for Primary Amputation of the Great Toe

Proceed with primary amputation if any of the following are present: 1

• Complete traumatic amputation with non-viable tissue
• Extensive tissue loss precluding skin coverage or creating high infectious risk
• Multiple fractures with bone loss or irreversible vascular ischemia
• Uncontrollable hemorrhagic shock despite resuscitation (where salvage would increase mortality risk)

Factors Favoring Limb Salvage

In hemodynamically stable patients without life-threatening injuries, pursue limb salvage when surgically feasible, as successful preservation yields superior psychological outcomes and quality of life. 1

• Functional results after delayed amputation are equivalent to those after immediate amputation, allowing continued rescue attempts when feasible. 1
• The absence of plantar sensation at presentation should NOT dictate amputation. 1
• High injury severity scores alone are NOT sufficient to mandate amputation. 1

Surgical Strategy Based on Patient Stability

For Hemodynamically Stable Patients

Perform early definitive surgical management within 24 hours, including thorough debridement, fracture stabilization, and wound coverage. 2, 3

• Surgical fixation is indicated when fracture displacement exceeds 2-3mm or any articular step-off is present. 3
• Great toe fractures requiring operative fixation should be treated with open reduction and internal fixation using screws or K-wires. 5, 4
• After definitive fixation, immobilize in a short leg walking boot or cast with toe plate for 2-3 weeks, then transition to a rigid-sole shoe for an additional 3-4 weeks. 6

For Hemodynamically Unstable or "Borderline" Patients

Apply damage-control orthopaedic surgery with temporary stabilization using K-wires and/or external fixation until the patient stabilizes. 1, 5

• This approach significantly reduces operative delays, blood loss, and respiratory complications. 1
• Once the patient stabilizes (typically 36-48 hours), schedule definitive orthopaedic surgery as early as possible, ideally within the first two weeks. 1
• Daily reassess hemodynamic status, respiratory function, acid-base balance, and coagulation profile. 1

For Multiply-Injured Patients with Complex Foot Trauma

If the patient has a high injury severity score (ISS >25) with severe associated injuries (GCS <9, severe coagulopathy, lactate >4 mmol/L), perform damage-control measures and delay definitive fixation. 7

• In multiply-injured patients with complex crush injury to the foot, primary amputation may be indicated to prevent life-threatening circulatory collapse. 7, 5
• The distinction between "life over limb" is critical—when definitive limb salvage would increase mortality risk, employ damage-control measures or proceed to immediate amputation. 1

Surgical Debridement Priorities

Perform urgent surgical debridement with thorough wound irrigation within 24-48 hours for open fractures. 2, 5

• Debridement must be radical, with amputation level selected at the most distal point compatible with tissue viability and wound healing. 5
• Investigate neurovascular injuries during debridement. 2
• Consider a second-look procedure within 24-48 hours after injury to reassess tissue viability. 5
• Free tissue transfer should be performed early if necessary for wound coverage. 5

Thromboprophylaxis

Initiate early pharmacological thromboprophylaxis with low molecular weight heparin after hemorrhage control and hemostasis are achieved, ideally within 36 hours of injury. 2, 3

Referral Indications

Refer immediately to orthopedic surgery for: 4

• Circulatory compromise
• Open fractures with significant soft tissue injury
• Fracture-dislocations
• Displaced intra-articular fractures
• Great toe fractures that are unstable or involve more than 25% of the joint surface

Critical Pitfalls to Avoid

• Never delay antibiotic administration in open fractures, as early prophylaxis significantly reduces infection rates. 1, 2
• Do not rely solely on severity scores for amputation decisions—comprehensive clinical assessment integrating cumulative injury burden, patient preferences, and surgeon expertise is necessary. 1
• Avoid using wound additives (antiseptics, soap) during irrigation, as they provide no benefit over saline alone. 2
• Do not miss compartment syndrome—the great toe has limited compartments, but severe crush injuries can cause compartment syndrome requiring immediate fasciotomy. 5

Multidisciplinary Rehabilitation

All patients with severe great toe trauma requiring potential amputation must be screened for psychosocial risk factors (PTSD, anxiety, low self-efficacy), which are major determinants of functional outcome. 1

• Multidisciplinary rehabilitation—including physical therapy, occupational therapy, and behavioral health interventions—improves both psychological well-being and functional recovery. 1
• Patients undergoing limb salvage typically require more subsequent interventions and rehospitalizations, whereas amputation is associated with shorter rehabilitation periods and fewer surgeries. 1