What are the next steps in managing a patient with a hyperflexed, bowed left great toe after a ladder fall, pain on weight‑bearing, and normal X‑ray without fracture?

Management of Hyperflexion Great Toe Injury with Normal X-rays

Given the hyperflexion mechanism and normal radiographs, you should obtain a CT scan of the foot to evaluate for occult fractures and soft-tissue injuries, as conventional radiographs are insufficient for acute hyperflexion injuries. 1

Immediate Advanced Imaging

• CT foot is the primary imaging technique recommended for acute hyperflexion injuries to the foot, as a study of 49 patients with this mechanism concluded that conventional radiographs (including weight-bearing views) are not sufficient for routine diagnostic workup 1, 2

• Conventional radiographs have moderate to poor sensitivity (25%-33%) for detecting injuries in hyperflexion trauma, missing significant fractures and ligamentous disruptions 1

• CT will identify occult metatarsal fractures, tarsal fractures (particularly cuboid), and joint malalignment that are not visible on plain films 2

Specific Injury Considerations

MTP Joint Injury Assessment

• The clinical presentation of a hyperflexed, bowed great toe with weight-bearing pain suggests possible plantar plate disruption or "sand toe" injury (hyperplantarflexion injury to the MTP joint) 3, 4

• If CT is negative but clinical suspicion remains high for soft-tissue injury, MRI is the preferred imaging method for evaluating the capsuloligamentous complex, plantar plate, and detecting occult fractures or bone contusions 1

• MRI has similar sensitivity to ultrasound for acute ligamentous and tendinous disruption but provides superior assessment of chondral and osteochondral lesions 1

Alternative Imaging Options

• Fluoroscopy can be used as an adjunct to assess sesamoid tracking with forced dorsiflexion, evaluating for MTP joint instability 1

• Ultrasound is sensitive for acute tendon rupture or dislocation but is not routinely used as first-line advanced imaging for MTP joint injury 1

Conservative Management Protocol

While awaiting or following imaging:

• Immobilization with taping or buddy taping to restrict motion 3, 4

• NSAIDs for pain and inflammation 3

• Ice and rest with non-weight-bearing or protected weight-bearing as tolerated 3

• Shoe wear modification (stiff-soled shoe or walking boot) to limit MTP joint motion 3

Critical Pitfalls to Avoid

• Do not rely solely on normal radiographs in hyperflexion injuries—this mechanism has high rates of radiographically occult injuries that require CT for detection 1, 2

• Do not miss Lisfranc injury—hyperflexion can cause midfoot ligamentous disruption without obvious radiographic findings; CT or MRI may be needed if midfoot tenderness is present 1

• Assess for dislocation—though rare, Type III MTP dislocations can occur and may require reduction (closed or surgical) 5, 6

Expected Recovery and Follow-up

• Hyperplantarflexion injuries ("sand toe") typically require 6 months for full recovery on average 3

• Common residual problems include loss of dorsiflexion (most common), persistent discomfort, and joint instability 3

• Initiate toe strengthening program once acute pain subsides 3

• Surgical intervention is reserved for confirmed unstable injuries, complete ligamentous disruption, or irreducible dislocations identified on advanced imaging 1, 2, 6