In a child with a Salter‑Harris type II fracture of the proximal phalanx of the fifth toe, does the management differ from standard toe fracture treatment?

Management of Salter-Harris Type II Fracture of the Fifth Toe Proximal Phalanx

Conservative management with buddy taping and a rigid-sole shoe is appropriate for this Salter-Harris type II fracture of the fifth toe, with no change from standard toe fracture treatment required. 1

Treatment Approach

Nondisplaced Salter-Harris type II fractures of the lesser toe phalanges can be managed by primary care physicians without orthopedic referral. 1 The fifth toe is considered a "lesser toe" (as opposed to the great toe), and selected nondisplaced Salter-Harris types I and II fractures in this location are specifically identified as appropriate for family physician management 1.

Specific Management Steps

• Immobilize with buddy taping to the adjacent fourth toe to provide stability while allowing some movement 1
• Prescribe a rigid-sole shoe to limit joint movement and protect the fracture during healing 1
• Avoid prolonged immobilization beyond what is necessary, as extended immobilization leads to stiffness and muscle atrophy 2

When Referral IS Required

Orthopedic referral would be indicated only if any of the following are present 1:

• Circulatory compromise
• Open fracture
• Significant soft tissue injury
• Fracture-dislocation
• Displaced intra-articular fracture
• Displacement requiring reduction (though even displaced lesser toe fractures can often be reduced and buddy-taped by the primary physician) 1

Key Distinction: Fifth Toe vs. Great Toe

The management differs significantly based on toe location 1:

• Fifth toe (lesser toe): Most Salter-Harris type II fractures, even if displaced, can be managed with closed reduction and buddy taping 1
• Great toe: Displaced fractures often require referral for stabilization, and fractures involving >25% of the joint surface or unstable fractures mandate specialist involvement 1

Prognosis

The prognosis for Salter-Harris type II fractures is excellent, as these injuries typically heal without growth disturbance. 3 A reported case of a 3-year-old with this exact injury (Salter-Harris type II of the fifth toe proximal phalanx) was successfully managed conservatively with no sequelae 4, and a similar case in a 10-year-old great toe showed good outcome at one year without adverse effects 5.

Growth Plate Considerations

• Salter-Harris type II fractures have favorable outcomes because the fracture line extends through the physis and into the metaphysis, typically preserving the germinal layer of the growth plate 3
• Risk of growth arrest is low for type II injuries compared to types III, IV, and V 3
• The risk depends on fracture type, location, patient age, vascularity, soft tissue state, and whether the injury is open or closed 4

Clinical Pitfalls to Avoid

• Do not over-treat lesser toe physeal fractures: The fifth toe requires less aggressive management than the great toe, and unnecessary immobilization or referral can lead to complications 1
• Do not obtain advanced imaging: Standard three-view radiographs are sufficient; CT, MRI, and other advanced modalities are not indicated for routine toe fractures 6, 7
• Monitor for displacement: While initial nondisplaced fractures can be managed conservatively, close follow-up is needed to ensure maintenance of alignment 8