Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon. Since the fragment is pulled away from the rest of the bone, this type of injury is called an avulsion fracture. After that, nonsurgical treatment options include six to eight weeks of short leg nonweight-bearing cast with radiographic follow-up to document healing at six to eight weeks.2,6,20 If evidence of healing is present (callus formation and lack of point tenderness) at that time, weight-bearing activity can progress gradually, along with physical therapy and rehabilitation. Radiographs often are required to distinguish these injuries from toe fractures. (Kay 2001) Complications: Posterior splint; nonweight bearing; follow-up in three to five days, Short leg walking cast with toe plate or boot for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to six weeks, Open fractures; fracture-dislocations; intra-articular fractures; fractures with displacement or angulation, Short leg walking boot or cast for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to eight weeks, Open fractures; fracture-dislocations; multiple metatarsal fractures; displacement > 3 to 4 mm in the dorsoplantar plane; angulation > 10 in the dorsoplantar plane, Three-view foot series with attention to the oblique view, Compressive dressing; ambulate as tolerated; follow-up in four to seven days, Short leg walking boot for two weeks, with progressive mobility and range of motion as tolerated; follow-up every two to four weeks; healing time of four to eight weeks, Repeat radiography at six to eight weeks to document healing, Displacement > 3 mm; step-off > 1 to 2 mm on the cuboid articular surface; fracture fragment that includes > 60% of the metatarsal-cuboid joint surface, Short leg nonweight-bearing cast for six to eight weeks; cast removal and gradual weight bearing and activity if radiography shows healing at six to eight weeks, or continue immobilization for four more weeks if no evidence of healing; healing time of six to 12 weeks, Repeat radiography at one week for stability and at the six- to eight-week follow-up; if no healing at six to eight weeks, repeat radiography at the 10- to 12-week follow-up, Displacement > 2 mm; 12 weeks of conservative therapy ineffective with nonunion revealed on radiography; athletes or persons with high activity level, Three-view foot series or dedicated phalanx series, Short leg walking boot; ambulate as tolerated; follow-up in seven days, Short leg walking boot or cast with toe plate for two to three weeks, then may progress to rigid-sole shoe for additional three to four weeks; follow-up every two to four weeks; healing time of four to six weeks, Repeat radiography at one week if fracture is intra-articular or required reduction, Fracture-dislocations; displaced intra-articular fractures; nondisplaced intra-articular fractures involving > 25% of the joint; physis (growth plate) fractures, Buddy taping and rigid-sole shoe; ambulate as tolerated; follow-up in one to two weeks, Buddy taping and rigid-sole shoe for four to six weeks; follow-up every two to four weeks; healing time of four to six weeks, Displaced intra-articular fractures; angulation > 20 in dorsoplantar plane; angulation > 10 in the mediolateral plane; rotational deformity > 20; nondisplaced intra-articular fractures involving > 25% of the joint; physis fractures. protected weightbearing with crutches, with slow return to running. Spiral fractures often lead to rotation or shortening, and transverse fractures lead to angulation.6. 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. This content is owned by the AAFP. Patients with Jones fractures should be referred if there is more than 2 mm of displacement, if conservative therapy is ineffective after 12 weeks of immobilization and radiography reveals nonunion, or if the patient is an athlete or is highly active.2,13,2022, Toe fractures are the most common fractures of the foot.23,24 Most fractures involve minimal displacement and are treated nonsurgically. 50(3): p. 183-6. J AmAcad Orthop Surg, 2001. Continue to learn and join meaningful clinical discussions . A fracture of the toe may result from a direct injury, such as dropping a heavy object on the front of your foot, or from accidentally kicking or running into a hard object. Following reduction, the nail bed of the fractured toe should lie in the same plane as the nail bed of the corresponding toe on the opposite foot. RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. Your doctor will tell you when it is safe to resume activities and return to sports. 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. (OBQ09.156) At the first follow-up visit, radiography should be performed to assure fracture stability. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Thank you. Because Jones fractures are located in an area with poor blood supply, they may take longer to heal. All material on this website is protected by copyright. Kensinger, D.R., et al., The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx. Hatch, R.L. Although tendon injuries may accompany a toe fracture, they are uncommon. Advertisement Almost two-thirds of all bones in the feet belong to the toes; hence the risk of fracture in this part of the foot is much higher than the rest of the foot. Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively, High rates of post-operative infection are common, Open reduction via an approach through the nail bed leads to significant post-operative nail deformity, Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively, Type in at least one full word to see suggestions list, Management of Proximal Phalanx Fractures & Their Complications, Middle Finger, Proximal Phalangeal Head - Bicondylar Fracture - Fixation, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. 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 ). Lgters TT, Fractures of the lesser toes are four times as common as fractures of the first toe.3 Most toe fractures are nondisplaced or minimally displaced. Referral is indicated if buddy taping cannot maintain adequate reduction. 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). Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) There are 3 phalanges in each toe except for the first toe, which usually has only 2. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. There is typically focal tenderness, swelling, and ecchymosis at the base of the fifth metatarsal. Referral also is recommended for children with first-toe fractures involving the physis.4 These injuries may require internal fixation. 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. If it does not, rotational deformity should be suspected. A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine. ORTHO BULLETS Orthopaedic Surgeons & Providers In children, toe fractures may involve the physis (Figure 2). Your doctor will take follow-up X-rays to make sure that the bone is properly aligned and healing. A fracture may also result if you accidentally hit the side of your foot on a piece of furniture on the ground and your toes are twisted or pulled sideways or in an awkward direction. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Copyright 2023 Lineage Medical, Inc. All rights reserved. abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. High-impact activities like running can lead to stress fractures in the metatarsals. Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Treatment Most broken toes can be treated without surgery. The nail should be inspected for subungual hematomas and other nail injuries. If you need surgery it is best that this be performed within 2 weeks of your fracture. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Phalanx Dislocations are common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP). In most cases, this is done by simply adjusting the direction of traction to correct any shortening, rotation, or malalignment. The most common injury in children is a fracture of the neck of the talus. More sensitive than an X-ray, an MRI can detect changes in the bone that may indicate a fracture. During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. 2017, Management of Proximal Phalanx Fractures & Their Complications, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Proximal Phalanx Fracture: Case of the Week - Michael Firtha, DO, Proximal Phalanx Fracture Surgery by Dr. Thomas Trumble, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. Proximal hallux. A combination of anteroposterior and lateral views may be best to rule out displacement. Great toe fractures are treated with a short leg walking boot or cast with toe plate for two to three weeks, then a rigid-sole shoe for an additional three to four weeks. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. Fractures can also develop after repetitive activity, rather than a single injury. toe phalanx fracture orthobullets A Jones fracture is a horizontal or transverse fracture at the base of the fifth metatarsal. Fracture of the proximal phalanx of the little finger in children: a classification and a method to measure the deformity . Tang, Pediatric foot fractures: evaluation and treatment. It ossifies from one center that appears during the sixth month of intrauterine life. 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. Pain that persists longer than a few months may indicate malunion, which may limit a patient's future activities significantly. Bony deformity is often subtle or absent. toe phalanx fracture orthobulletsdaniel casey ellie casey. See permissionsforcopyrightquestions and/or permission requests. The middle phalanx (P2) is dislocated or subluxated dorsally, and the volar lip is fractured at its base. Published studies suggest that family physicians can manage most toe fractures with good results.1,2. This usually occurs from an injury where the foot and ankle are twisted downward and inward. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. On exam, he is neurovascularly intact. 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. fractures of the head of the proximal phalanx. The appropriate treatment depends on the location of the fracture, the amount of displacement (shifting of the two ends of the fracture), and activity level of the patient. A fracture, or break, in any of these bones can be painful and impact how your foot functions. Lesser toe fractures are about twice as common as great toe fractures.23,24 The great toe has an increased role in weight bearing and balance; thus, injury to the great toe is associated with higher morbidity.6,24, The primary goals of treating toe fractures include reestablishing and maintaining alignment, regaining range of motion, and preventing complications. Ribbans, W.J., R. Natarajan, and S. Alavala, Pediatric foot fractures. 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. X-rays. Fractures of the talus include fractures of the neck, body, medial or lateral process, and osteochondral injuries. The injured toe should be compared with the same toe on the other foot to detect rotational deformity, which can be done by comparing nail bed alignment. The proximal phalanx is the toe bone that is closest to the metatarsals. Healing of a broken toe may take 6 to 8 weeks. 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. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). Copyright 2016 by the American Academy of Family Physicians. These bones comprise 2 bones in the hindfoot (calcaneus, talus), [ 1, 2] 5 bones in the midfoot (navicular, cuboid, 3. Copyright 2003 by the American Academy of Family Physicians. 24(7): p. 466-7. Copyright 2023 Lineage Medical, Inc. All rights reserved. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. 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). Started in 1995, this collection now contains 6407 interlinked topic pages divided into a tree of 31 specialty books and 722 chapters. Acute fractures to the proximal fifth metatarsal bone: Development of classification and treatment recommendations based on the current evidence. A proximal phalanx is a bone just above and below the ball of your foot. Healing time is typically four to six weeks. What is the optimal treatment for the proximal phalanx fracture shown in Figure A? 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. 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. Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury. 21(1): p. 31-4. Foot Ankle Int, 2015. Proper . A fracture that is not treated can lead to chronic foot pain and arthritis and affect your ability to walk. (Right) An intramedullary screw has been used to hold the bone in place while it heals. Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. Bite The Bullet, He Needs Long Term Function: Be The Hated Person - Robert Anderson, MD. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow). Joint hyperextension and stress fractures are less common. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. 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. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. . This is called a "stress fracture.". If an acute subungual hematoma is present (less than 24 hours old), decompression may relieve pain substantially. Comminution is common, especially with fractures of the distal phalanx. 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. 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. Mounts, J., et al., Most frequently missed fractures in the emergency department. 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. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. 36(1)p. 60-3. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? In one rural family practice,1 toe fractures comprised 8 percent of 295 fractures diagnosed; in an Air Force family practice residency program,2 they made up 9 percent of 624 fractures treated. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. The proximal fragment flexes due to interossei, and the distal phalanx extends due to the central slip. In most cases, a fracture will heal with rest and a change in activities. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Copyright 2023 Lineage Medical, Inc. All rights reserved. Others use a cast that fixates the wrist, metacarpophalangeal joint and proximal phalanx but allows movement of the interphalangeal joints. As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. Taping may be necessary for up to six weeks if healing is slow or pain persists. 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. Unless it is fairly subtle, rotational deformity should be corrected by further manipulation. (Left) The four parts of each metatarsal. This webinar will address key principles in the assessment and management of phalangeal fractures. These include metatarsal fractures, which account for 35% of foot fractures.2,3 About 80% of metatarsal fractures are nondisplaced or minimally displaced, which often makes conservative management appropriate.4 In adults and children older than five years, fractures of the fifth metatarsal are most common, followed by fractures of the third metatarsal.5 Toe fractures, the most common of all foot fractures, will also be discussed. This is called internal fixation. 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. Open fractures, Infection, Compartment syndrome 3; References, Classification, Courses 3; Distal articular. 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. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. An avulsion fracture is also sometimes called a "ballerina fracture" or "dancer's fracture" because of the pointe position that ballet dancers assume when they are up on their toes. Copyright 2023 American Academy of Family Physicians. An MRI is performed and selected cuts are shown in Figures B and C. What is this patients diagnosis? Sesamoid bones generally are present within flexor tendons in the first toe (Figure 1, top) and are found less commonly in the flexor tendons of other toes. The metatarsals are the long bones between your toes and the middle of your foot. Avertical Lachman test will show greater laxity compared to the contralateral side. If stable, the patient can be transitioned to a short leg walking cast or boot3,6 (Figures 411 and 5). 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. We help you diagnose your Toe fractures case and provide detailed descriptions of how to manage this and hundreds of other pathologies . Distal metaphyseal. Salter-Harris type II fractures of the proximal phalanx are the most common type of finger fracture. There should be at least three images of the affected toe, including anteroposterior, lateral, and oblique views, with visualization of the adjacent toes and of the joints above and below the suspected fracture location. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. Differential Diagnosis The same mechanisms that produce toe fractures. Early surgical management of a Jones fracture allows for an earlier return to activity than nonsurgical management and should be strongly considered for athletes or other highly active persons. However, return to work and sport can generally take six to eight weeks depending on activity level; some high-level athletes may require more time.6, Initial management of lesser toe fractures (Figure 14) includes buddy taping to an adjacent toe, use of a rigid-sole shoe, and ambulation as tolerated. We help you diagnose your Hand Proximal phalanx case and provide detailed descriptions of how to manage this and hundreds of other pathologies. (OBQ05.226) Great toe fractures are generally treated with a short leg walking cast with a toe plate (Figure 1311 ) that extends past the great toe or with a short leg walking boot for two to three weeks.6 After this time, and in the absence of significant symptoms, the patient can progress to buddy taping and use of a rigid-sole shoe for three to four weeks.6,23,24 Range-of-motion exercises can generally be initiated at four weeks. Nail bed injury and neurovascular status should also be assessed. Proximal interphalangeal joint (PIPJ) dislocation is one of the most common hand injuries. 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. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. and S. Hacking, Evaluation and management of toe fractures. Physical examination reveals marked tenderness to palpation. All the bones in the forefoot are designed to work together when you walk. (Left) In this X-ray, a fracture in the proximal phalanx of the fifth toe (arrow) has caused the toe to become deformed. A 34-year-old male sustains the closed finger injury shown in Figure A one week ago. 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: The proximal phalanx is the phalanx (toe bone) closest to the leg. It is one of the most common fractures of the foot and has unique characteristics that make it more likely to require surgery. Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. The reduced fracture is splinted with buddy taping. While many Phalangeal fractures can be treated non-operatively, some do require surgery. Diagnosis requires radiographic evaluation, although emerging evidence demonstrates that ultrasonography may be just as accurate. (Left) In this X-ray, a recent stress fracture in the third metatarsal is barely visible (arrow). At the conclusion of treatment, radiographs should be repeated to document healing. The proximal phalanx is the toe bone that is closest to the metatarsals. For several days, it may be painful to bear weight on your injured toe. Phalangeal fractures are the most common foot fracture in children. Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, He Is Playing With Nonoperative Treatment - Michael Coughlin, MD, He Is Out!
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