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. (Right) An intramedullary screw has been used to hold the bone in place while it heals. Copyright 2023 Lineage Medical, Inc. All rights reserved. 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. If the bone is out of place, your toe will appear deformed. About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an FAAOS Surgeon. They most often involve the metatarsals and toes. Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx, Intrinsic muscle fibrosis and intrinsic minus contracture, PIP joint volar plate attenuation and extensor tendon disruption, Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands, Flexor tendon disruption with associated overpull of the extensor mechanism. If more than 25% of the joint surface is involved or if the displacement is more than 2 to 3 mm, closed or open reduction is indicated. If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. 118(2): p. e273-8. In children, toe fractures may involve the physis (Figure 2). Nail bed injury and neurovascular status should also be assessed. 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. 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. Fractures of the toes and forefoot are quite common. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. Thus, this article provides general healing ranges for each fracture. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. There are 3 phalanges in each toe except for the first toe, which usually has only 2. Objective Evidence However, if you have fractured several metatarsals at the same time and your foot is deformed or unstable, you may need surgery. Since the fragment is pulled away from the rest of the bone, this type of injury is called an avulsion fracture. Pain is worsened with passive toe extension. (Left) In this X-ray, a fracture in the proximal phalanx of the fifth toe (arrow) has caused the toe to become deformed. If you need surgery it is best that this be performed within 2 weeks of your fracture. Surgeons will learn to assess and evaluate phalangeal anatomy and fracture geometry. 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. Follow-up/referral. There is typically focal tenderness, swelling, and ecchymosis at the base of the fifth metatarsal. However, overlying shadows often make the lateral view difficult to interpret (Figure 1, center). Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. Ulnar gutter splint/cast. A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine. 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. Returning to activities too soon can put you at risk for re-injury. 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. Copyright 2016 by the American Academy of Family Physicians. A Jones fracture is a horizontal or transverse fracture at the base of the fifth metatarsal. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. Petnehazy, T., et al., Fractures of the hallux in children. 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 Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. (Left) The four parts of each metatarsal. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. 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. You will be given a local anesthetic to numb your foot, and your doctor will then manipulate the fracture back into place to straighten your toe. Treatment Most broken toes can be treated without surgery. Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). Your foot may become swollen and discolored after a fracture. (SBQ17SE.3) 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. Reduction of fractures in children can usually be accomplished by simple traction and manipulation; open reduction is indicated if a satisfactory alignment is not obtained. The Ottawa Ankle and Foot Rules should be used to help determine whether radiography is needed when evaluating patients with suspected fractures of the proximal fifth metatarsal. Copyright 2023 American Academy of Family Physicians. Injuries to this bone may act differently than fractures of the other four metatarsals. (Left) In this X-ray, a recent stress fracture in the third metatarsal is barely visible (arrow). Management is determined by the location of the fracture and its effect on balance and weight bearing. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. This is called internal fixation. Foot phalanges. These tendons may avulse small fragments of bone from the phalanges; they also can be injured when a toe is fractured. Copyright 2023 American Academy of Family Physicians. CrossRef Google Scholar PubMed 7 DeVries, JG, Taefi, E, Bussewitz, BW, Hyer, CF, Lee, TH. A combination of anteroposterior and lateral views may be best to rule out displacement. This content is owned by the AAFP. The use of musculoskeletal ultrasonography may be considered to diagnose subtle metatarsal fractures. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Pediatrics, 2006. Data Sources: We searched the Cochrane database, Essential Evidence Plus, and PubMed from 1900 to the present, human studies only, using the key words foot fractures, metatarsal, toe, and phalanges fractures. Physical examination reveals marked tenderness to palpation. Open subtypes (3) Lesser toe fractures. Spiral fractures often lead to rotation or shortening, and transverse fractures lead to angulation.6. Joint hyperextension and stress fractures are less common. Remodeling of the fracture callus generally produces an almost normal appearance of the bone over a matter of months (Figure 26-36). Epub 2012 Mar 30. Radiographs often are required to distinguish these injuries from toe fractures. Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations (Figure 5), displaced intra-articular fractures, and fractures that are difficult to reduce. Concerns with delayed healing and/or high activity demands may result in your doctor recommending surgery for an acute Jones fracture as well. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. Kensinger, D.R., et al., The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. Copyright 2023 Lineage Medical, Inc. All rights reserved. (SBQ17SE.89) Comminution is common, especially 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). Diagnosis can be made clinically and are confirmed with orthogonal radiographs. (OBQ12.89) 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. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. The pull of these muscles occasionally exacerbates fracture displacement. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx (Figure 2). 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. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. Clin J Sport Med, 2001. 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. Foot fractures are among the most common foot injuries evaluated by primary care physicians. ORTHO BULLETS Orthopaedic Surgeons & Providers Search dates: February and June 2015. X-rays. 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. This joint sits between the proximal phalanx and a bone in the hand . Rotator Cuff and Shoulder Conditioning Program. Others use a cast that fixates the wrist, metacarpophalangeal joint and proximal phalanx but allows movement of the interphalangeal joints. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. 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. Proximal interphalangeal joint (PIPJ) dislocation is one of the most common hand injuries. In some practice sites, family physicians manage open toe fractures; a discussion about the management of this type of injury can be found elsewhere.3,4 Patients also may require referral because of delayed complications such as osteomyelitis from open fractures, persistent pain after healing, and malunion. - 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; 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). A radiograph, bone scan, and MRI are found in Figures A-C, respectively. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. stress fracture of the proximal phalanx MRI indications positive bone scan hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture abnormal radiographs persistent pain, swelling, weak toe push-off not recommended routinely findings will show disruption of volar plate 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. All material on this website is protected by copyright. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. In many cases, anteroposterior and oblique views are the most easily interpreted (Figure 1, top and bottom). The skin should be inspected for open fracture and if . Surgical repair is indicated for patients with progressive and persistent symptoms who fail nonoperative management. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. 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. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. Other symptoms may include: If you think you have a fracture, it is important to see your doctor as soon as possible. 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. Fractures can affect: Causes of lesser toe (phalangeal) fractures Trauma (generally something heavy landing on the toe or kicking an immovable object) Treatment of lesser toe (phalangeal) fractures Non-displaced 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. Patients usually present with a painful, swollen, ecchymotic toe with variable deformity and gait disturbance. (OBQ05.209) Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon. He undergoes closed reduction and pinning shown in Figure B to correct alignment. They typically involve the medial base of the proximal phalanx and usually occur in athletes. Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. 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. What is the most likely diagnosis? 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. If there is a break in the skin near the fracture site, the wound should be examined carefully. An X-ray can usually be done in your doctor's office. Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. 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. Although tendon injuries may accompany a toe fracture, they are uncommon. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) This topic will review the evaluation and management of toe fractures in adults. Pearls/pitfalls. Thompson, T.M., et al., Foot injuries associated with all-terrain vehicle use in children and adolescents. 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. Jones fractures are located in a watershed area for blood supply (zones 2 and 3) and have high rates of delayed union and nonunion17 (Figure 10). High-impact activities like running can lead to stress fractures in the metatarsals. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Taping may be necessary for up to six weeks if healing is slow or pain persists. Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head, Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach, Open reduction and lag screw fixation with 1.3mm screws through a radial approach, Placement of a 1.5-mm condylar blade plate through a radial approach, Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint. 3 Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. Management is influenced by the severity of the injury and the patient's activity level. While many Phalangeal fractures can be treated non-operatively, some do require surgery. Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). Some metatarsal fractures are stress fractures. 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. Avertical Lachman test will show greater laxity compared to the contralateral side. They can also result from the overuse and repetitive stress that comes with participating in high-impact sports like running, football, and basketball.
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