How should I manage a distal phalanx base fracture of the great toe with point tenderness and an incidental Achilles enthesophyte, and when is MRI indicated?

Management of Great Toe Distal Phalanx Base Fracture

Treat this fracture conservatively with buddy taping to the second toe and a rigid-sole shoe for 4-6 weeks, with no need for immediate MRI unless symptoms persist beyond 3 weeks or you suspect an open fracture, displaced intra-articular involvement, or instability. 1

Initial Assessment and Red Flags

Your X-ray shows a questionable base fracture of the distal phalanx with point tenderness—this clinical correlation is critical because certain features mandate immediate orthopedic referral:

• Open fracture indicators: Bleeding at the nail base, laceration proximal to the nail fold, or visible bone require urgent surgical evaluation for possible open reduction and K-wire fixation 2
• Displacement >25% of joint surface: Great toe fractures involving this much articular surface are unstable and need referral 1
• Fracture-dislocation or significant intra-articular displacement: These require surgical stabilization 1
• Circulatory compromise or significant soft tissue injury: Immediate referral indicated 1

If none of these red flags are present, proceed with conservative management.

Conservative Management Protocol

For stable, nondisplaced or minimally displaced fractures (which appears to be your case):

• Buddy taping: Tape the great toe to the second toe with padding between digits to prevent skin maceration 1
• Rigid-sole shoe: This limits joint movement and protects the fracture during healing 1
• Weight-bearing as tolerated: Most toe fractures heal well with protected weight-bearing 1
• Duration: Continue immobilization for 4-6 weeks 1
• NSAIDs: For pain control as needed 3

When to Order MRI

MRI is NOT indicated initially for a visible fracture with appropriate clinical findings. 4 The ACR guidelines are clear that MRI serves a specific role:

• Persistent pain beyond 1-3 weeks with normal radiographs: MRI without IV contrast is appropriate for occult injuries 3
• Suspected osteochondral injury: When radiographs are equivocal but clinical suspicion remains high 4
• Ligamentous injury concern: Not applicable to your phalangeal fracture 4

Since you already have a fracture identified on X-ray with corresponding point tenderness, the radiologist's suggestion to "consider MRI if clinically indicated" applies only if the patient fails conservative treatment or develops unexpected symptoms. 3

The Achilles Enthesophyte

This is an incidental finding unrelated to your acute fracture and requires no immediate action. 4

• Enthesophytes are degenerative bone spurs at tendon insertions
• Address only if the patient develops posterior heel pain or Achilles symptoms
• Does not affect fracture management

Follow-Up Algorithm

Week 2-3: Clinical reassessment for healing progression

• If improving: Continue conservative management
• If worsening or no improvement: Consider repeat radiographs to assess alignment 1

Week 4-6: Transition to regular footwear as tolerated

• Most stable fractures heal by 6 weeks 1
• Return to normal activities gradually

Beyond 6 weeks with persistent pain:

• Obtain MRI without IV contrast to evaluate for occult complications (nonunion, osteochondral injury) 3
• Consider referral to foot and ankle specialist 3

Common Pitfalls to Avoid

• Over-imaging: Do not order MRI for a clearly visible fracture with appropriate clinical findings—this adds cost without changing initial management 4
• Missing open fractures: Always examine for nail bed injury or lacerations suggesting open fracture, especially in "stubbed toe" mechanisms 2
• Inadequate immobilization: Buddy taping alone without rigid-sole shoe allows excessive motion and delays healing 1
• Premature return to activity: Great toe fractures require full healing before impact activities to prevent displacement 1