What is the recommended management for a minimally displaced fracture of a lesser toe (second‑to‑fifth toe), and how should treatment be modified in patients with diabetes, peripheral vascular disease, neuropathy, or immunosuppression?

Management of Minimally Displaced Lesser Toe Fractures

For minimally displaced fractures of the lesser toes (2nd-5th), treat with buddy taping to an adjacent toe and a rigid-sole shoe for 4-6 weeks, allowing immediate weight-bearing as tolerated. 1, 2

Standard Treatment Protocol

Buddy taping with rigid-sole footwear is the definitive treatment for stable, minimally displaced lesser toe fractures. 1 This approach provides:

• Immediate pain relief through fracture stabilization rather than relying solely on medications 3
• Progressive weight-bearing as pain permits, which does not compromise healing and may improve outcomes 3
• Duration of 4-6 weeks with buddy taping maintained throughout this period 1, 2

The rigid-sole shoe limits joint movement at the fracture site, which is essential for proper healing. 1

Pain Management

• Start with scheduled paracetamol (acetaminophen) as first-line analgesia unless contraindicated 3, 4
• Add opioids cautiously if needed, particularly avoiding them if renal function is unknown 3
• Avoid NSAIDs if renal dysfunction is suspected 3, 4
• Early immobilization provides superior analgesia compared to medications alone 3

Modified Approach for High-Risk Patients

Patients with Diabetes

For diabetic patients with lesser toe fractures, even minimally displaced injuries require prolonged immobilization and strict non-weight-bearing if neuropathy is present. 5 This is critical because:

• Diabetic patients with neuropathy lack protective sensation, placing them at risk for progression to neuroarthropathic (Charcot) changes 6, 5
• Rigorous offloading is mandatory to prevent complications and deformity progression 4, 5
• Prolonged immobilization periods beyond the standard 4-6 weeks are necessary for stable, minimally displaced injuries 5
• Daily foot inspection is essential to identify early complications 6

Patients with Peripheral Vascular Disease (PAD)

• Assess lower-extremity pulses, capillary refill time, rubor on dependency, and pallor on elevation before initiating treatment 6
• Obtain ankle-brachial index with toe pressures if pulses are diminished or absent 6
• Ensure meticulous foot care including appropriate footwear and daily inspection to prevent skin breakdown 6

Patients with Neuropathy (Non-Diabetic)

• Apply the same rigorous offloading principles as for diabetic neuropathy 4
• Special attention to pressure distribution is required since these patients cannot sense excessive pressure or early complications 6

Immunosuppressed Patients

• Monitor closely for signs of infection including wound breakdown, erythema, or systemic symptoms 6
• Maintain strict wound hygiene if any skin compromise is present 6
• Lower threshold for specialist referral if healing is delayed or complications arise 6

Indications for Orthopedic Referral

Refer immediately for:

• Displaced fractures of the great toe (first toe), which often require stabilization 1
• Fracture-dislocations of any toe 1
• Displaced intra-articular fractures 1
• Open fractures or significant soft tissue injury 1
• Circulatory compromise (blue, purple, or pale appearance) 3, 1
• Unstable fractures in diabetic patients, particularly those with neuropathy, which may require open reduction and internal fixation to prevent neuroarthropathic progression 5

Follow-Up and Monitoring

• Obtain regular radiographic assessment to ensure proper healing and alignment 4
• Begin physical training and muscle strengthening immediately after immobilization removal to prevent stiffness and muscle atrophy 3, 4
• Continue balance training beyond initial healing, particularly in elderly patients at risk for falls 3, 4

Common Pitfalls to Avoid

• Do not apply compression wraps too tightly, as this can compromise circulation 3
• Do not place ice directly on skin if using cryotherapy 3
• Do not underestimate the risk in diabetic patients with neuropathy—what appears minimally displaced can progress to severe deformity without proper offloading 5
• Do not delay vascular assessment in patients with PAD, as the combination of fracture and ischemia portends poor outcomes 6