(Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. Which of the following structures most often prevents closed reduction of this injury? (SBQ17SE.3) Comminution is common, especially with fractures of the distal phalanx. Magnetic Resonance Imaging (MRI) scans. Commence antibiotics (cefalexin or cefazolin first line) toe mtp joint approach dorsomedial orthobullets topic. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. Proximal phalanx extraarticular fractures, Middle phalanx dorsal and palmar lip fractures (pilon). Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures. Diagnosis can be made clinically and are confirmed with orthogonal radiographs. Where buddy taping is performed, the parent should observe the method in case re-application is required in the coming weeks (including placing cotton between the toes to prevent skin maceration) 118(2): p. e273-8. Diagnosis of Closed Fracture of Toe Bones (Phalanges) Referral also is recommended for children with first-toe fractures involving the physis.4 These injuries may require internal fixation. (OBQ11.63) This information is provided as an educational service and is not intended to serve as medical advice. A 28-year-old male injures his hand while playing basketball and presents to the emergency room. (OBQ06.173) 21(1): p. 31-4. Open subtypes (3) Lesser toe fractures. 2 ). Distal Radius Buckle (Torus) Fracture This fracture is a common injury in children. There are 3 phalanges in each toe except for the first toe, which usually has only 2. Abstract. In young children this is most often from crush . (Left) In this X-ray, a recent stress fracture in the third metatarsal is barely visible (arrow). <5yrs discuss with local Orthopaedic team as reduction success rate may be affected by size of phalanx, Can typically be reduced and buddy taped, in ED (place some cotton between the toes to prevent skin maceration) Wear supportive shoe until pain resolves (usually 3 weeks). Other symptoms may include: If you think you have a fracture, it is important to see your doctor as soon as possible. She has no plantar ecchymosis but does have tenderness over her lateral foot. Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. General Fracture Management. Proximal fractures in children Your doctor will then examine your foot and may compare it to the foot on the opposite side. Sesamoids And Accessory Ossicles Of The Foot: Anatomical Variability link.springer.com The distal phalanx and border digits are most commonly injured. Buddy taping the small finger to the ring finger, Immobilization of the MCP in flexion and the PIP and DIP in extension with a custom splint, Type in at least one full word to see suggestions list, Cleveland Combined Hand Fellowship Lecture Series 2018-2019, PIP Dorsal Fracture Dislocation - Timothy Fei, MD. See permissionsforcopyrightquestions and/or permission requests. Infections can reach a bone by spread from surrounding tissue or can reach the bone from the blood stream. What is the optimal treatment for the proximal phalanx fracture shown in Figure A? All the bones in the forefoot are designed to work together when you walk. 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. Vollman, D. and G.A. J AmAcad Orthop Surg, 2001. Pain is worsened with passive toe extension. An AP radiograph is shown in FIgure A. Which of the following radiographs demonstrates an injury that would be treated best by dorsal extension block splinting? and C.W. The same mechanisms that produce toe fractures may cause a ligament sprain, contusion, dislocation, tendon injury, or other soft tissue injury. Type I fractures are due to the longitudinal force applied through the physis, which splits the epiphysis from the metaphysis. Treatment Most broken toes can be treated without surgery. Copyright 2023 American Academy of Family Physicians. Patients usually present with a painful, swollen, ecchymotic toe with variable deformity and gait disturbance. High-impact activities like running can lead to stress fractures in the metatarsals. Rest, ice, elevation. It is also important to check for significant nailbed injury. Petnehazy, T., et al., Fractures of the hallux in children. Care should be taken in cases with degenerative changes where a tiny detached osteophyte can also mimic as a tiny fracture fragment. Case Discussion. When this happens, surgery is often required. (OBQ05.209) During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. a 19-year old collegiate football lineman sustains a twisting injury to his right foot 1 week ago and radiographs are shown in Figure A. A fractured toe may become swollen, tender, and discolored. screw and plate fixation. They are most commonly used to treat fractures of the fifth metatarsal (the bone at the base of the big toe). Toe fractures are relatively common and frequently managed by primary care and emergency physicians. Lisfranc injury), divided into tuberosity, base, metadiaphysis, diaphysis, neck, and head, is primarily cancellous and highly vascularized, site of peroneus brevis and lateral band of plantar fascia insertion, open apophysis or os peroneum may be confused for fracture (comparison radiographs warranted), has no tendinous attachments and is vascular watershed, peroneus tertius inserts on dorsal diaphysis, articulates with proximal phalanx to form metatarsophalangeal joint, blood supply provided by metaphyseal vessels and diaphyseal nutrient artery, fifth metatarsal forms lateral border of forefoot, functions as a lever in gait during push-off, Due to long plantar ligament, lateral band of the plantar fascia, or contraction of the peroneus brevis, Involves the 4th-5th metatarsal articulation, Distal to the 4th-5th metatarsal articulation, Associated with cavovarus foot deformities or sensory neuropathies, Narrow fracture line without intramedullary sclerosis, Widened fracture line with intramedullary sclerosis, Widened intramedullary canal with no callus, antecedent pain in setting of stress fracture, rapid increase in workload or change in training regimen, tenderness to palpation along bone at fracture site, excessive lateral wear pattern on shoe treads, evaluate for lateral ligamentous instability and whether varus hindfoot is correctable, pain with resisted foot eversion (indicates peroneal tendon weakness), intramedullary sclerosis and lack of periosteal callus reaction indicative of chronicity, callus forms medially first and progresses laterally, plantar fracture gap lends poor prognosis, plantarflexed first metatarsal and high Meary's angle indicating cavovarus deformity, suspicion for stress fracture with equivocal radiographs, to evaluate degree of fracture healing in setting of delayed/nonunion or following surgical fixation, suspicion for stress fracture with equivocal radiographs or bone scan, zone 1 fracture without rotational displacement, union achieved by 8 weeks, fibrous unions are infrequently symptomatic, early return to work but symptoms may persist for up to 6 months, high non-union rate and risk of re-fracture approaching 33% in zone 2 fractures, zone 1 fractures with rotational displacement or skin tenting, zone 2 (Jones fracture) in elite or competitive athletes, minimizes possibility of nonunion or prolonged restriction from activity, zone 3 fractures in athletic individuals, cavovarus alignment, or with sclerosis/nonunion (Torg Types 2-3), bony union rates approaching 100% in most series, salvage for nonunion following intramedullary screw fixation, early data show plate and screw construct has equivalent strength to intramedullary fixation, advance weight bearing as tolerated by pain, advance weight bearing with signs of radiographic callus (around 4-6 weeks), zone 3 fractures often require 6-7 weeks of non-weight bearing immobilization, reports of extracorpeal shock wave with similar union rates as internal fixation for zone 3 stress fractures, patient supine with bump under hip and fluoroscopy immediately available, short longitudinal incision proximal to tuberosity, parallel with plantar surface, blunt dissection past sural nerve branches to tuberosity, between peroneus longus and brevis tendons, using fluoroscopy, K-wire starting position superior and medial on tuberosity ("high and inside" position), k-wire does not need to be passed further than the metatarsal curvature, k-wire placed intramedullary, fluoroscopy to confirm location, soft tissue protector placed and wire may be removed or cannulated drill used to open canal and drill pilot hole, sequentially tap to be able to place screw, tap can be used to measure appropriate length screw, 4.5mm, 5.5mm, or 6.5mm diameter partially-threaded screw placed, recommended to use the largest diameter screw that can be accommodated, if fracture gap persists or in cases of nonunion/revision, bone graft material may be added at fracture site, short period of non-weight bearing (1-3 weeks) followed by protected weightbearing and beginning therapy focusing on range of motion and non-impact aerobic exercises, running and impact activities commenced at 6 weeks if surgical site pain-free and signs of radiographic callus, longitudinal incision centered over proximal 5th metatarsal, typical plantar fracture gap and/or rotational displacement able to be reduced, 3mm plate bent to contour to plantar-lateral surface of bone to compress fracture, nonunion rates for Zone 2 injuries are as high as 15-30%, zone 2 and zone 3 fractures due to vascular supply, smaller diameter screws (<4.5mm) associated with delayed or nonunion, nutritional (vitamin-D) or hormonal (thyroid) deficiencies, revision intramedullary screw fixation with use of bone grafting, return to sports prior to radiographic union, fracture distraction or malreduction due to screw length, screws that are too long will straighten the curved metatarsal shaft or perforate the medial cortex, screw that is too short will not compress fracture, cavovarus foot deformity, stress fractures, vitamin-D insufficiency, removal of intramedullary screw, internal fixation with surgical correction of cavovarus deformity if present, leave screw in place until end of patient's athletic career, rare complication following intramedullary screw fixation, screw head left prominent can irritate sural nerve branches, prominent screw head impinging on nerve branches, dorsolateral branch of sural nerve within 2-3 mm of tuberosity, prevented by using tissue protector during procedure and sinking screw head, uncommon, result of zone 1 fracture nonunion after initial conservative treatment, fragment excision and reattachment of peroneus brevis tendon, Posterior Tibial Tendon Insufficiency (PTTI). The reduced fracture is splinted with buddy taping. A fracture of proximal phalanx in patients who engage in regular sports activities was reported only rarely, after it was first reported by Hukko and Orava in 1987. Fractures of the big toe should be followed up in fracture clinic, due to its role at the end of the stance phase in the gait cycle, Refer to Orthopaedics Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Referral should be strongly considered for patients with nondisplaced intra-articular fractures involving more than 25 percent of the joint surface (Figure 4).4 These fractures may lose their position during follow-up. A collegiate soccer player presents as a referral to your office after sustaining an injury to the right foot, which he describes as hyperdorsiflexion of the toes. Displaced Salter Harris fractures of the great toe may cause joint stiffness or growth arrest. Which of the following is the most appropriate initial treatment? Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. A combination of anteroposterior and lateral views may be best to rule out displacement. Thompson, T.M., et al., Foot injuries associated with all-terrain vehicle use in children and adolescents. 2. Abstract. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. Impacted fracture of the second toe proximal phalanx. Collegiate soccer player with an acute nondisplaced zone 2 proximal 5th metatarsal fracture, High school varsity lacrosse player with a subacute zone 2 proximal 5th metatarsal fracture and no evidence of bony healing after 1 month of conservative management, Elite dancer with an acute zone 1 proximal 5th metatarsal fracture, Recreational football player with an acute zone 2 proximal 5th metatarsal fracture. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. 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. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. usually associated with distal phalanx fractures, comprised of proper and accessory collateral ligaments, both originate from middle phalanx condyles, proper collateral ligament inserts on volar base of distal phalanx, accessory collateral ligament inserts on volar plate, act as restraint against radial and ulnar deviation, both originate from proximal phalanx condyles, proper collateral ligament inserts on volar base of middle phalanx, forms 2 checkrein ligaments proximally that attach to proximal phalanx, skin puckering may indicate interposition of soft tissues within the joint, important to assess stability of the joint after reduction, perform with joint in full extension and in 30 of flexion, assesses competency of collateral ligaments when stressed in flexion, collateral ligament injury can be classified into 3 grades, grade II - laxity with firm endpoint and stable arc of motion, grade III - gross instability with no endpoint, assesses competency of secondary stabilizers (bony anatomy, accessory collateral ligaments, volar plate) when stressed in extension, ability to achieve full ROM indicates stable joint, traction neuropraxia may occur due to stretching of adjacent digital nerves, diagnosis confirmed by history, physical exam, and radiographs, dorsal dislocations are more common than volar dislocations, results from PIPJ hyperextension with longitudinal compression (i.e. Diagnosis is made with plain radiographs of the foot. Case Discussion. The finger is ecchymotic, swollen throughout, and painful with attempted range of motion of the PIP joint. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. They are frequently related to sports, with lesions such as the mallet finger and the Jersey finger.
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