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. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. Patients have localized pain, swelling, and inability to bear weight on the. Patients usually present with a painful, swollen, ecchymotic toe with variable deformity and gait disturbance. Fractures of the proximal phalanx of the hallux involving the epiphysis may be intra-articular. Vollman, D. and G.A. 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. (OBQ05.209) Concerns with delayed healing and/or high activity demands may result in your doctor recommending surgery for an acute Jones fracture as well. Bruising or discoloration your foot may be red or ecchymotic ("black and blue"), Loss of sensation an indication of nerve injury, Head which makes a joint with the base of the toe, Neck the narrow area between the head and the shaft, Base which makes a joint with the midfoot. While on call at the local rural community hospital, you're called by an emergency medicine colleague. Narcotic analgesics may be necessary in patients with first-toe fractures, multiple fractures, or fractures requiring reduction. This content is owned by the AAFP. A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. Therefore, phalanges and digits adjacent to the fracture must be examined carefully; joint surfaces also must be examined for intra-articular fractures (Figure 3). Thus, this article provides general healing ranges for each fracture. A 34-year-old male sustains the closed finger injury shown in Figure A one week ago. 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. Fracture Fixation, Internal Bone Plates Fracture Fixation Bone Nails Fracture Fixation, Intramedullary Bone Screws Bone Wires Range of Motion, Articular Hemiarthroplasty Arthroplasty Casts, Surgical Treatment Outcome Arthroplasty, Replacement Internal Fixators Retrospective Studies Bone Transplantation Reoperation Injury . Nail bed injury and neurovascular status should also be assessed. Thank you. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. 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. Pearls/pitfalls. 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. 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. 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 ). The localized tenderness of a contusion may mimic the point tenderness of a fracture. Although tendon injuries may accompany a toe fracture, they are uncommon. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. (Right) An intramedullary screw has been used to hold the bone in place while it heals. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. A, Dorsal PIPJ fracture-dislocation. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Comminution is common, especially with fractures of the distal phalanx. In most cases, a fracture will heal with rest and a change in activities. Clinical Features Stress fractures can occur in toes. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) Fractures of the toes and forefoot are quite common. At the conclusion of treatment, radiographs should be repeated to document healing. 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). 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. The younger the child, the more . There are 3 phalanges in each toe except for the first toe, which usually has only 2. Radiographs often are required to distinguish these injuries from toe fractures. Surgery is not often required. - 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; An attempt at reduction and immobilization is made in the field by his unit physician assistant, and he returns to your office one week later. 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. Hatch, R.L. Hand (N Y). 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. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. 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). Examination should consist of a neurovascular evaluation and palpation of the foot and ankle. laceration bone talks, extensor tendon injuries hand orthobullets, flexor and extensor tendon injuries phoenix az arizona, tendon lacerations twin boro physical therapy, repair and rehabilitation of extensor hallucis longus and, extensor mechanism injury hip amp knee book, Ribbans, W.J., R. Natarajan, and S. Alavala, Pediatric foot fractures. As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. 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). Radiographs are shown in Figure A. Surgery may be delayed for several days to allow the swelling in your foot to go down. The flexor and extensor tendons impart a longitudinal compression force, which can shorten the phalanx and extend the distal fragment [ 1 ]. (OBQ18.111) Because Jones fractures are located in an area with poor blood supply, they may take longer to heal. Displaced fractures of the first toe generally are managed similarly to displaced fractures of the lesser toes. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. Clin OrthopRelat Res, 2005(432): p. 107-15. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for four to six weeks. This information is provided as an educational service and is not intended to serve as medical advice. Plate fixation . Kay, R.M. Treatment is generally straightforward, with excellent outcomes. 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. Management is determined by the location of the fracture and its effect on balance and weight bearing. Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. Foot radiography is required if there is pain in the midfoot zone and any of the following: bone tenderness at point C (base of the fifth metatarsal) or D (navicular), or inability to bear weight immediately after the injury and at the time of examination.14 When used properly, the Ottawa Ankle and Foot Rules have a sensitivity of 99% and specificity of 58%, with a positive likelihood ratio of 2.4 and a negative likelihood ratio of 0.02 for detecting fractures. Copyright 2023 Lineage Medical, Inc. All rights reserved. (OBQ09.156) This is called a "stress fracture.". 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. If there is a break in the skin near the fracture site, the wound should be examined carefully. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. X-rays. Deformity, decreased range of motion, and degenerative joint disease in this toe can impair a patient's functional ability. 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. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. One of the most common foot fractures in children, Open fractures require irrigation & debridement, Nail-bed injuries involving the germinal matrix should be repaired, Displaced intra-articular fractures of the hallux require reduction. Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit. Copyright 2023 American Academy of Family Physicians. Follow-up/referral. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. 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. Turf Toe is a hyperextension injury to the plantar plate and sesamoid complex of the big toe metatarsophalangeal joint that most commonly occurs in contact athletic sports. A combination of anteroposterior and lateral views may be best to rule out displacement. If the bone is out of place, your toe will appear deformed. 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. The metatarsals are the long bones between your toes and the middle of your foot. Patients with open toe fractures or fractures with overlying skin necrosis are at high risk for osteomyelitis. myAO. More sensitive than an X-ray, an MRI can detect changes in the bone that may indicate a fracture. Diagnosis requires radiographic evaluation, although emerging evidence demonstrates that ultrasonography may be just as accurate. 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. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. Joint hyperextension, a less common mechanism, may cause spiral or avulsion fractures. 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. Primary care physicians are often the first clinicians patients see for foot injuries, and fractures are among the most common foot injuries they evaluate.1 This article will highlight some common foot fractures that can be managed by primary care physicians. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. 5th metatarsal most commonly fractured in adults, 1st metatarsal most commonly fractured in children less than 4 years old, 3rd metatarsal fractures rarely occur in isolation, 68% associated with fracture of 2nd or 4th metatarsal, peak incidence between 2nd and 5th decade of life, may have significant associated soft tissue injury, occurs with forefoot fixed and hindfoot or leg rotating, Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures, consider metabolic evaluation for fragility fracture, shape and function similar to metacarpals of the hand, first metatarsal has plantar crista that articulates with sesamoids, muscular balance between extrinsic and intrinsic muscles, Metatarsals have dense proximal and distal ligamentous attachments, 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with isolated fractures, implicated in formation of interdigital (Morton's) neuromas, multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to increased displacement, Classification of metatarsal fractures is descriptive and should include, look for antecedent pain when suspicious for stress fracture, foot alignment (neutral, cavovarus, planovalgus), focal areas or diffuse areas of tenderness, careful soft tissue evaluation with crush or high-energy injuries, evaluate for overlapping or malrotation with motion, semmes weinstein monofilament testing if suspicious for peripheral neuropathy, AP, lateral and oblique views of the foot, may be of use in periarticular injuries or to rule out Lisfranc injury, useful in detection of occult or stress fractures, second through fourth (central) metatarsals, non-displaced or minimally displaced fractures, evaluate for cavovarus foot with recurrent stress fractures, sagittal plane deformity more than 10 degrees, restore alignment to allow for normal force transmission across metatarsal heads, lag screws or mini fragment plates in length unstable fracture patterns, maintain proper length to minimize risk of transfer metatarsalgia, limited information available in literature, may lead to transfer metatarsalgia or plantar keratosis, treat with osteotomy to correct deformity, Majority of isolated metatarsal fractures heal with conservative management, Malunion may lead to transfer metatarsalgia, Posterior Tibial Tendon Insufficiency (PTTI). A proximal phalanx is a bone just above and below the ball of your foot. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. He undergoes closed reduction and pinning shown in Figure B to correct alignment. 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. Avertical Lachman test will show greater laxity compared to the contralateral side. Search dates: February and June 2015. Most patients with acute metatarsal fractures report symptoms of focal pain, swelling, and difficulty bearing weight. Ulnar side of hand. Patients with circulatory compromise require emergency referral. It ossifies from one center that appears during the sixth month of intrauterine life. In children, toe fractures may involve the physis (Figure 2). Patients typically present with pain, swelling, ecchymosis, and difficulty with ambulation. A 55 year-old woman comes to you with 2 months of right foot pain. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. Unless it is fairly subtle, rotational deformity should be corrected by further manipulation. J Pediatr Orthop, 2001. Minimally displaced (less than 3 mm) avulsion fractures typically require immobilization and support with a short leg walking boot. Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. 11(2): p. 121-3. 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. Epub 2017 Oct 1. 9(5): p. 308-19. 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. 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. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. from the American Academy of Orthopaedic Surgeons, Bruising or discoloration that extends to nearby parts of the foot. Fracture position ideally will be maintained when traction is released, but in some cases the reduction can be held only with buddy taping. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Repeat radiography is indicated and should be obtained one week post-fracture if there was intra-articular involvement or if a reduction was required. 3 Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. 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. While many Phalangeal fractures can be treated non-operatively, some do require surgery. Differential Diagnosis The same mechanisms that produce toe fractures. Magnetic Resonance Imaging (MRI) scans. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? 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 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. Physical examination findings typically include tenderness to palpation, swelling, ecchymosis, and sometimes crepitation at the fracture site. See permissionsforcopyrightquestions and/or permission requests. Am Fam Physician, 2003. Thompson, T.M., et al., Foot injuries associated with all-terrain vehicle use in children and adolescents. X-rays provide images of dense structures, such as bone. Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured.

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