Toe Fracture

General indications
1. Perfusion defect (emergency)
2. Open Toe Fracture (suspected or actual)
3. Skin necrosis overlying Fracture site
Great Toe Fracture indications (includes general above)
1. First Toe Fracture-dislocation
2. Displaced intra-articular Fracture
3. Unstable displaced Fractures
4. Children with Fracture involving physis
5. Nondisplaced intra-articular Fracture >25% of joint
Lesser Toe Fracture indications (includes general)
1. Fracture dislocations
2. Displaced intra-articular Fractures
3. Children with Salter-Harris Fractures III to V
4. Angulation >20 degrees in dorsoplantar plane or rotation, or >10 degrees in mediolateral plane

Reduce displaced Fracture as with Lesser Toe Fractures (see below)
1. Great toe is key to weight bearing, walking and balance
2. Alignment is more critical for great toe than for the lesser toes
Initial: Immobilization
1. Short Leg Walking Cast with toe plate or short leg walking boot for 2-3 weeks
2. Continue immobilization if persistent symptoms
Next: Progress if minimal symptoms
1. Buddy taping and rigid-soled shoe for 3-4 weeks
2. Start range of motion Exercises at 4 weeks
Referral Indications
1. Inadequate or unstable reduction
2. Open Fracture
3. Intraarticular Fracture persistently displaced or >25% of joint involved
4. Persistent rotation
5. Severe crush injury
6. Neurovascular compromise
7. Contaminated wound
Follow great toe XRays
1. Post-reduction films
2. Repeat in 7-10 days (5 days for a child)
3. Repeat weekly if unstable or intra-articular Fracture
Healing course
1. Expect 4-6 weeks total
2. Athletes may require >8 weeks to return fully to activity

Acute management for first 72 hours
1. Rest
2. Ice Therapy for 20 minutes of each hour (avoid Frostbite)
3. Elevation
Splinting 3-6 weeks until non-tender
1. Hard soled shoe AND
2. Buddy taping Fractured toe to adjacent toe
  1. Use cotton padding between toes and tape together
  2. Re-tape every 2-3 days
3. Alternatives
  1. Consider Walking boot or Short Leg Walking Cast if pain not controlled with hard shoe and taping
Referral Indications
1. Similar to Great Toe referral indications (see above)
Follow-up care
1. Follow-up in 1-2 weeks and then every 2-4 weeks until fully healed
2. Repeat XRay is optional in non-displaced Fractures
  1. Repeat XRay at 7-10 days for Fractures requiring reduction or more than 25% joint involved
3. Work on range of motion until matches opposite toe

Digital Block to anesthetize affected toe
Reduce Fracture with longitudinal traction
Continue manipulation if rotational deformity
1. Toe nail should lie in same plan as adjacent toes
Splint with buddy taping after reduction (see above)
Refer if reduction not maintained in splint (or other referral indications as above)

Decompress with needle or cautery
Avoid nail removal if possible
1. Acts as distal phalanx splint
2. Some recommend nail removal for Hematoma >50%
  1. Explore wound and suture Nail Bed Laceration