How should an intra‑articular toe fracture be evaluated and managed?

Management of Intra-Articular Toe Fractures

Intra-articular toe fractures require plain radiographs for diagnosis, and most should be managed conservatively with buddy taping and rigid-sole footwear, but displaced fractures of the great toe and any fracture with significant soft tissue injury, circulatory compromise, or involving >25% of the joint surface require orthopedic referral. 1, 2, 3

Initial Diagnostic Evaluation

Obtain standard radiographs (anteroposterior, lateral, and oblique views) when there is point tenderness at the fracture site or pain with gentle axial loading of the digit. 1, 2, 3

• Do not apply Ottawa Ankle Rules to toe injuries—these rules specifically exclude distal forefoot trauma, so obtain radiographs based on clinical suspicion alone 1
• CT scanning is not indicated for initial evaluation of simple toe fractures and should be reserved only for complex fractures requiring surgical planning 4
• Advanced imaging with MRI should be considered only for patients with persistent pain beyond expected healing time to evaluate for occult injuries 2

Immediate Referral Criteria

Refer immediately to orthopedic surgery if any of the following are present: 2, 3

• Circulatory compromise or blue/purple/pale appearance of the toe 2
• Open fractures 3
• Significant soft tissue injury 2, 3
• Fracture-dislocations 3
• Displaced intra-articular fractures 3
• Great toe fractures that are unstable or involve >25% of the joint surface 3

Conservative Management Protocol

For Stable, Non-Displaced Intra-Articular Fractures

Treat with buddy taping to the adjacent toe and a rigid-sole shoe to limit joint movement. 1, 3

• Before buddy taping, clean and dry both the injured toe and adjacent toe, covering any open wounds with a clean dressing 2
• Apply non-elastic adhesive tape in a figure-of-eight pattern around both toes, firm enough for stability but not so tight as to compromise circulation 2
• Check capillary refill after taping to ensure adequate circulation 2
• Avoid over-immobilization—prolonged rigid immobilization leads to stiffness and muscle atrophy, while buddy taping allows controlled motion while protecting the fracture 1

Pain Management

• Use NSAIDs as needed for analgesia 1
• Early fracture stabilization through proper immobilization provides the most effective pain relief 1

Weight-Bearing and Activity

• Transition to protected weight-bearing as pain allows 4
• Most patients return to full activity without limitation, though this may take several weeks 5

Special Considerations for Great Toe Intra-Articular Fractures

Great toe intra-articular fractures warrant more aggressive evaluation and lower threshold for referral compared to lesser toe fractures. 2, 3

• Displaced fractures of the first toe often require referral for stabilization of the reduction 3
• Consider turf toe (plantar plate disruption) if there is a history of hyperextension injury—this may require weight-bearing radiographs with sesamoid axial views 2
• Intra-articular fractures of the great toe in children have a high complication rate after surgical intervention (60% in one series), though most patients were ultimately asymptomatic at long-term follow-up 5

Critical Pitfalls to Avoid

• Do not underestimate the severity of intra-articular involvement—even small amounts of articular incongruity can lead to post-traumatic arthritis, as intra-articular fractures carry significant risk for this complication 6, 7
• Do not miss circulatory compromise—assess toe color and capillary refill before and after any immobilization 2
• Do not apply tuft fracture management principles to intra-articular fractures—while tuft fractures are inherently stable, intra-articular fractures require assessment of joint surface involvement and displacement 1
• Do not delay referral for displaced intra-articular fractures—anatomic reduction is critical for optimal outcomes, and the likelihood of good to excellent outcomes increases when anatomic reduction is obtained 8

Follow-Up and Monitoring

• Monitor for persistent pain beyond expected healing time (typically 6-8 weeks), which may indicate complications requiring advanced imaging 2
• Watch for development of post-traumatic arthritis, particularly in fractures with residual articular incongruity 6, 7
• Patients with intra-articular fractures should be counseled about the risk of long-term functional deficits and chronic pain, even with appropriate initial management 8, 7