There are 3 phalanges in each toe except for the first toe, which usually has only 2. Proximal hallux. The thumb connects to the hand through the next joint, known as the metacarpophalangeal (MCP) joint. toe phalanx fracture orthobulletsdaniel casey ellie casey. Dislocation refers to displacement in which the two articular surfaces are no longer in contact, in contrast to subluxation, in which there is some contact (may be referred to as complete versus simple dislocation in some texts). Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. Deformity, decreased range of motion, and degenerative joint disease in this toe can impair a patient's functional ability. The preferred splinting technique is to buddy tape the affected toe to an adjacent toe (Figure 7).4 Treatment should continue until point tenderness is resolved, usually at least three weeks (four weeks for fractures of the first toe). . Bicondylar proximal phalanx fractures usually are treated with plate fixation. Your video is converting and might take a while Feel free to come back later to check on it. The first toe has only two phalanges; the second through the fifth toes generally have three, but the fifth toe sometimes can have only two (Figure 1). (Left) X-ray shows a Jones fracture at the base of the fifth metatarsal (arrow). Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? The "V" sign (arrow) indicates dorsal instability. Since the fragment is pulled away from the rest of the bone, this type of injury is called an avulsion fracture. Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. If the reduction is unstable (i.e., the position is not maintained after traction is released), splinting should not be used to hold the reduction, and referral is indicated. If an avulsion fracture results in a large displaced fracture fragment, however, your doctor may need to do an open reduction and internal fixation with plates and/or intramedullary screws. If the wound communicates with the fracture site, the patient should be referred. ORTHO BULLETS Orthopaedic Surgeons & Providers The collateral ligaments and volar plate at the metacarpophalangeal (MCP) joint stabilize the proximal portion and the extensor tendon pulls the distal fragment into extension. Open fractures, Infection, Compartment syndrome 3; References, Classification, Courses 3; Distal articular. When performed on 18 children with distal radius-ulna fractures, P_STAR achieved near anatomic fracture alignment with no nerve or tendon injury, infection, or refracture. Referral is indicated in patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, displaced intra-articular fractures, or fractures of the first toe that are unstable or involve more than 25 percent of the joint surface. Deformity of the digit should be noted; most displaced fractures and dislocations present with visible deformity. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. The patient notes worsening pain at the toe-off phase of gait. The reduced fracture is splinted with buddy taping. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. This is called internal fixation. Referral also is recommended for children with first-toe fractures involving the physis.4 These injuries may require internal fixation. Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Surgical fixation involves Kirchner wires or very small screws. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. Ulnar side of hand. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Therefore, phalanges and digits adjacent to the fracture must be examined carefully; joint surfaces also must be examined for intra-articular fractures (Figure 3). J AmAcad Orthop Surg, 2001. METHODS: We reviewed the most current literature on various treatment methods of proximal phalanx fractures, focusing on the indications and outcomes of nonoperative as well as operative interventions. After anesthetizing the toe with ice or a digital block, the physician holds the tip of the toe, applies longitudinal traction, and manipulates the bone fragments into proper position. Fracture position ideally will be maintained when traction is released, but in some cases the reduction can be held only with buddy taping. All rights reserved. A fracture, or break, in any of these bones can be painful and impact how your foot functions. (OBQ11.63) If this maneuver produces sharp pain in a more proximal phalanx, it suggests a fracture in that phalanx. Plate fixation . The talus has a head, constricted neck, and body. Each metatarsal has the following four parts: Fractures can occur in any part of the metatarsal, but most often occur in the neck or shaft of the bone. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. and C.W. Search dates: February and June 2015. Which of the following acute fracture patterns would best be treated with open reduction and internal fixation? An MRI is performed and selected cuts are shown in Figures B and C. What is this patients diagnosis? During the procedure, your doctor will make an incision in your foot, then insert pins or plates and screws to hold the bones in place while they heal. The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. Type in at least one full word to see suggestions list, 2022 California Orthopaedic Association Annual Meeting, COA Foot and Ankle End - Glenn Pfeffer, MD, Comminuted Fifth Metatarsal Fracture in 28M. Magnetic Resonance Imaging (MRI) scans. Petnehazy, T., et al., Fractures of the hallux in children. There is typically swelling, ecchymosis, and point tenderness to palpation at the fracture site. (Right) An intramedullary screw has been used to hold the bone in place while it heals. The localized tenderness of a contusion may mimic the point tenderness of a fracture. Epub 2017 Oct 1. Fractures of the proximal phalanx of the hallux involving the epiphysis may be intra-articular. There is evidence that transitioning to a walking boot and then to a rigid-sole shoe (Figure 6) at four to six weeks, with progressive weight bearing as tolerated, results in improved functional outcomes compared with cast immobilization, with no differences in healing time or pain scores.12, Follow-up visits should occur every two to four weeks, with repeat radiography at four to six weeks to document healing.3,6 At six weeks, callus formation on radiography and lack of point tenderness generally signify adequate healing, after which immobilization can be discontinued.2,3,6. Abductor, interosseus, and adductor muscles insert at the proximal aspects of each proximal phalanx. (SBQ17SE.89) Some metatarsal fractures are stress fractures. Your next step in management should consist of: Percutaneous biopsy and referral to an orthopaedic oncologist, Walker boot application and evaluation for metabolic bone disease, Referral to an orthopaedic oncologist for limb salvage procedure, Internal fixation of the fracture and evaluation for metabolic bone disease, Metatarsal-cuneiform fusion of the Lisfranc joint. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. In this type of injury, the tendon that attaches to the base of the fifth metatarsal may stretch and pull a fragment of bone away from the base. Indications for referral of patients with first metatarsal fractures are different because the first metatarsal has a vital role in weight bearing and arch support. They can also result from the overuse and repetitive stress that comes with participating in high-impact sports like running, football, and basketball. The fifth metatarsal is the long bone on the outside of your foot. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. This content is owned by the AAFP. Fractures of the talus include fractures of the neck, body, medial or lateral process, and osteochondral injuries. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for four to six weeks. most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). Patients with unstable fractures and nondisplaced, intra-articular fractures of the lesser toes that involve more than 25 percent of the joint surface (Figure 3) usually do not require referral and can be managed using the methods described in this article. If you experience any pain, however, you should stop your activity and notify your doctor. 24(7): p. 466-7. Unless it is fairly subtle, rotational deformity should be corrected by further manipulation. At the conclusion of treatment, radiographs should be repeated to document healing. The Ottawa Ankle and Foot Rules should be applied when examining patients with suspected fractures of the proximal fifth metatarsal to help decide whether radiography is needed14 (Figure 815 ). Copyright 2023 Lineage Medical, Inc. All rights reserved. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Fractures of multiple phalanges are common (Figure 3). Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. All material on this website is protected by copyright. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. Stress fractures can occur in toes. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. Because it is the longest of the toe bones, it is the most likely to fracture. While many Phalangeal fractures can be treated non-operatively, some do require surgery. imbalance after flexor tendon repair seems to be thus, extensor tendon injuries occur frequently an in depth understanding of the intricate anatomy of the extensor mechanism is necessary to guide management careful counseling is helpful in Toe fracture (Redirected from Toe Fracture) Contents 1 Background 2 Clinical Features 3 Differential Diagnosis 3.1 Foot and Toe Fractures 3.1.1 Hindfoot 3.1.2 Midfoot 3.1.3 Forefoot 4 Management 4.1 General Fracture Management 4.2 Immobilization 5 Disposition 6 See Also 7 References Background Bones of the foot. If you need surgery it is best that this be performed within 2 weeks of your fracture. Three muscles, viz. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). While you are waiting to see your doctor, you should do the following: When you see your doctor, they will take a history to find out how your foot was injured and ask about your symptoms. If you have an open fracture, however, your doctor will perform surgery more urgently. More sensitive than an X-ray, an MRI can detect changes in the bone that may indicate a fracture. Foot fractures range widely in severity, prognosis, and treatment. Although adverse outcomes can occur with toe fractures,3 disability from displaced phalanx fractures is rare.5. However, if you have fractured several metatarsals at the same time and your foot is deformed or unstable, you may need surgery. All critical aspects of phalangeal fracture care will be discussed with pertinent case examples. Hatch, R.L. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. Epidemiology Incidence Follow-up visits should be scheduled every two weeks, and healing time varies from four to eight weeks.3,6 Follow-up radiography is typically required only at six to eight weeks to document healing, or earlier if the patient has persistent localized pain or continued painful ambulation at four weeks.2,3,6. Proximal interphalangeal joint (PIPJ) dislocation is one of the most common hand injuries. Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured. Management is determined by the location of the fracture and its effect on balance and weight bearing. They typically involve the medial base of the proximal phalanx and usually occur in athletes. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. Copyright 2016 by the American Academy of Family Physicians. In most cases, a fracture will heal with rest and a change in activities. 21(1): p. 31-4. All Rights Reserved. Because it is the longest of the toe bones, it is the most likely to fracture. Recent studies have demonstrated that musculoskeletal ultrasonography and traditional radiography have comparable accuracy, sensitivity, and specificity in the diagnosis of foot and ankle fractures9,10 (Figure 1). Nondisplaced or minimally displaced (less than 2 mm) fractures of the lesser toes with less than 25% joint involvement and no angulation or rotation can be managed conservatively with buddy taping or a rigid-sole shoe. Diagnosis requires radiographic evaluation, although emerging evidence demonstrates that ultrasonography may be just as accurate. Common presenting symptoms include bruising, swelling, and throbbing pain that worsens with a dependent position, although this type of pain also may occur with an isolated subungual hematoma. A standard foot series with anteroposterior, lateral, and oblique views is sufficient to diagnose most metatarsal shaft fractures, although diagnostic accuracy depends on fracture subtlety and location.7,8 However, musculoskeletal ultrasonography can provide a quick bedside assessment without radiation exposure that accurately assesses overt and subtle nondisplaced fractures. In children, toe fractures may involve the physis (Figure 2). A proximal phalanx is a bone just above and below the ball of your foot. Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit. Most children with fractures of the physis should be referred, but children with selected nondisplaced Salter-Harris types I and II fractures may be treated by family physicians. Despite theoretic risks of converting the injury to an open fracture, decompression is recommended by most experts.5 Toenails should not be removed because they act as an external splint in patients with fractures of the distal phalanx. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. Examination should consist of a neurovascular evaluation and palpation of the foot and ankle. Note that the volar plate (VP) attachment is involved in the . Background: The goal of proximal phalangeal fracture management is to allow for fracture healing to occur in acceptable alignment while maintaining gliding motion of the extensor and flexor tendons. These rules have been validated in adults and children.16 If radiography is indicated, a standard foot series with anteroposterior, lateral, and oblique views is sufficient to make the diagnosis. A Jones fracture has a higher risk of nonunion and requires at least six to eight weeks in a short leg nonweight-bearing cast; healing time can be as long as 10 to 12 weeks. protected weightbearing with crutches, with slow return to running. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) The image shows a diagram of where these bones lie in the footthe midpoint of the proximal phalanges being where to the toes branch off from the main body of the foot. ClinPediatr (Phila), 2011. Hallux fractures. The proximal phalanx is the toe bone that is closest to the metatarsals. Patients usually present with a painful, swollen, ecchymotic toe with variable deformity and gait disturbance. The next bone is called the proximal phalanx. We help you diagnose your Hand Proximal phalanx case and provide detailed descriptions of how to manage this and hundreds of other pathologies. The nail should be inspected for subungual hematomas and other nail injuries. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Proximal phalanx fractures - displaced or unstable If a proximal phalanx fracture is displaced or if the fracture pattern is unstable it is likely that surgery will be recommended. Healing rates also vary considerably depending on the age of the patient and comorbidities. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). Ribbans, W.J., R. Natarajan, and S. Alavala, Pediatric foot fractures. When this happens, surgery is often required. A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. Patients with these fractures should be referred to an orthopedist.2,3,6, The fifth metatarsal has the least cortical thickness of all the metatarsals.13 There are multiple strong ligamentous and capsular attachments surrounding the proximal fifth metatarsal; these allow stresses to be directed through this portion of the bone.13 Classically, fractures of the proximal fifth metatarsal can be classified based on anatomic location into one or more of three zones (Figure 7).3. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine. Patients typically present with pain, swelling, ecchymosis, and difficulty with ambulation. In an analysis of 339 toe fractures, 95% involved less than 2 mm of displacement and all fractures were managed conservatively with good outcomes.25, The most common mechanisms of injury are axial loading (stubbing) or crush injury. What is the most likely diagnosis? Evidence has shown that, depending on symptoms, short leg walking boots are superior to short leg walking casts.18,19 Immobilization in a cast or boot is typically only needed for two weeks, with progressive ambulation and range of motion thereafter as tolerated. Injury. Metatarsal shaft fractures most commonly occur as a result of twisting injuries of the foot with a static forefoot, or by excessive axial loading, falls from height, or direct trauma.2,3,6 Patients may have varying histories, ranging from an ill-defined fall to a remote injury with continued pain and trouble ambulating. 2017 Oct 01;:1558944717735947. The video will appear on the video dashboard once complete. Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). Metatarsal shaft fractures near the head or base of the first to fourth metatarsal with any degree of displacement or angulation are often associated with concomitant injuries and generally take longer to heal. Most fifth metatarsal fractures can be treated with weight bearing as tolerated, and immobilization in a cast or walking boot. (OBQ05.209) Diagnosis can be made clinically and are confirmed with orthogonal radiographs. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. (Left) The four parts of each metatarsal. Nondisplaced or minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts with less than 10 of angulation can be treated conservatively with a short leg walking boot, cast shoe, or elastic bandage, with progressive weight bearing as tolerated. Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures. The distal phalanx is the most common location for a non-physeal injury which typically involves a crushing mechanism, and the most common location for physeal injury is the proximal phalanx. X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow). Published studies suggest that family physicians can manage most toe fractures with good results.1,2. Patients with circulatory compromise require emergency referral. Objective Evidence Kay, R.M. Nail bed injury and neurovascular status should also be assessed. Common mechanisms of injury include: Axial loading (stubbing toe) Abduction injury, often involving the 5th digit Crush injury caused by a heavy object falling on the foot or motor vehicle tyre running over foot Less common mechanism: If it does not, rotational deformity should be suspected. 11(2): p. 121-3. Diagnosis is made with plain radiographs of the foot. Stress fractures are typically caused by repetitive activity or pressure on the forefoot. (SBQ17SE.3) A fifth metatarsal tuberosity avulsion fracture can be treated acutely with a compressive dressing, then the patient can be transitioned to a short leg walking boot for two weeks, with progressive mobility as tolerated after initial immobilization. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. 2 ). Examination of the metatarsals should include palpation of the metatarsal base, shaft, and head, as well as examination of the proximal tarsometatarsal and distal metatarsophalangeal joints. rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website. - See: Phalangeal Injury Menu: - Discussion: - fractures of the proximal phalanx are potentially the most disabling fractures in the hand; - direct blows tend to cause transverse or comminuted frx, where as twisting injury may cause oblique or spiral fracture; - proximal fragments are usually flexed by intrinsics while distal fragments are extended due to extrinsic compressive forces; A positive metatarsal loading test, which involves manual axial loading of the metatarsal, may exacerbate the pain and help differentiate a fracture from a soft tissue injury.3. Returning to activities too soon can put you at risk for re-injury. Toe and forefoot fractures often result from trauma or direct injury to the bone. Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. To check proper alignment, radiographs should be taken immediately after reduction and again seven to 10 days after the injury (three to five days in children).4 In patients with potentially unstable or intra-articular fractures of the first toe, follow-up radiographs should be taken weekly for two or three weeks to monitor fracture position. Thus, this article provides general healing ranges for each fracture. If a fracture is present, it will typically be one of two types: a tuberosity avulsion fracture or a Jones fracture (i.e., proximal fifth metatarsal metadiaphyseal fracture). Adjacent metatarsals should be examined, and neurovascular status should be assessed. In P_STAR, 2 distraction pins are placed 1.5 cm proximal and distal to the fracture site in clearance of the distal radial physis. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. (OBQ12.89) ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. For several days, it may be painful to bear weight on your injured toe. Surgery is required in the case of an open fracture, when there is significant displacement, or instability after reduction. Management is influenced by the severity of the injury and the patient's activity level. Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. The most common phalanx fractures involve the border digits, namely, the index and small finger rays (Fig. Open subtypes (3) Lesser toe fractures. They most often involve the metatarsals and toes. Referral is indicated if buddy taping cannot maintain adequate reduction. Which of the following is true regarding open reduction and screw fixation of this injury? You can rate this topic again in 12 months. Copyright 2003 by the American Academy of Family Physicians. Phalanx fractures are classified by the following: Phalangeal fractures are the most common foot fracture in children. The proximal phalanx is the phalanx (toe bone) closest to the leg. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. Follow-up/referral. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.