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. Finger (Phalanx) Fracture Proximal Middle Distal Examination Evaluate for tendon damage Always look for a second fracture Imaging Hand Xrays to rule out additional fractures Comminuted tuft fracture Tuft's fracture Stable Longitudinal fracture Usually non-displaced and stable Transverse fracture Evaluate for angulation/displacement Unstable, displaced phalanx fractures require surgical management, preferably via closed reduction and percutaneous pinning. A 23-year-old professional lacrosse player injures her left foot while walking down a flight of stairs. Therefore, phalanges and digits adjacent to the fracture must be examined carefully; joint surfaces also must be examined for intra-articular fractures (Figure 3). Closed reduction is performed and is stable. A combination of anteroposterior and lateral views may be best to rule out displacement. 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). If you don't have an RSS reader, we suggest Digg or Feedly. He is currently tender to palpation on the lateral border of the foot. Patients with intra-articular fractures are more likely to develop long-term complications. Plain film dorsoplantar, oblique and lateral views should be ordered where there is a suspected open fracture, a suspected fracture with associated angulation, a nailbed injury, or for any fracture of the great (1st) toe. The flexor and extensor tendons impart a longitudinal compression force, which can shorten the phalanx and extend the distal fragment [ 1 ]. It can be hard to appreciate on the normal views, but there is a break in the cortex with some angulation, and closer views show the impacted fracture. In young children this is most often from crush . 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 Intramedullary screw fixation approach patient supine with bump under hip and fluoroscopy immediately available percutaneous/ limited open approach (SBQ18FA.12) A radiograph of her foot is found in Figure A. The nail should be inspected for subungual hematomas and other nail injuries. Deformity of the digit should be noted; most displaced fractures and dislocations present with visible deformity. <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) Kensinger, D.R., et al., The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx. After the splint is discontinued, the patient should begin gentle range-of-motion (ROM) exercises with the goal of achieving the same ROM as the same toe on the opposite foot. Fractures of the foot account for approximately 5% to 13% of all pediatric fractures. fracture phalanx distal toe radiopaedia nail small bed version . Your foot may become swollen and discolored after a fracture. 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. AP, lateral, and oblique radiographs are provided in Figures A, B, and C respectively. Comminuted fracture of first toe at the distal aspect of the terminal phalanx. 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. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. (OBQ07.218) Bruising or discoloration your foot may be red or ecchymotic ("black and blue"), Loss of sensationan 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. The pain is worsened with weightbearing and walking. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. What is the optimal treatment for the proximal phalanx fracture shown in Figure A? 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 2003 by the American Academy of Family Physicians. 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. Patients with open toe fractures or fractures with overlying skin necrosis are at high risk for osteomyelitis. Some metatarsal fractures are stress fractures. (SBQ07SM.41) It is important to check for angulation/mal-alignment and for rotational deformity (the position of the nail plate will give a guide to this and compare with toes on the other foot) In which of the following scenarios would early surgical intervention be indicated? An 19-year-old elite dancer falls and sustains the injury seen in Figure A. A radiograph is provided in Figure 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. Joint hyperextension and stress fractures are less common. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Unlike an X-ray, there is no radiation with an MRI. He was initially treated with a short leg splint, non-weight bearing and elevation. The skin should be inspected for open wounds or significant injury that may lead to skin necrosis. If the bone is out of place, your toe will appear deformed. Unstable phalangeal fractures: treatment by A.O. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. 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. Diagnosis is made with plain radiographs of the foot. 11 The factors that cause fracture include wrong training and repetitive trauma; 8 fracture can also occur while wearing tight shoes or starting high-intensity training without warm-up. The patient notes worsening pain at the toe-off phase of gait. As your pain subsides, however, you can begin to bear weight as you are comfortable. A radiograph, bone scan, and MRI are found in Figures A-C, respectively. The localized tenderness of a contusion may mimic the point tenderness of a fracture. 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. Heal rapidly- within 3 to 4 weeks A common complication of toe fractures is persistent pain and a decreased tolerance for activity. 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. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. Irrigate wound Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. Avertical Lachman test will show greater laxity compared to the contralateral side. Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. Which of the following is the primary advantage of operative intervention for these fractures compared to non-operative treatment? Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Application of a gentle axial loading force distal to the injury (i.e., compressing the distal phalanx toward the foot) may distinguish contusions from fractures. Pain in the foot. To enhance comfort, some patients prefer to cut out the part of the shoe that overlies the fractured toe. In many cases, anteroposterior and oblique views are the most easily interpreted (Figure 1, top and bottom). (OBQ12.89) Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. This webinar will address key principles in the assessment and management of phalangeal fractures. An MRI is performed and selected cuts are shown in Figures B and C. What is this patients diagnosis? Diagnosis can be made clinically and are confirmed with orthogonal radiographs. Which of the following is true regarding open reduction and screw fixation of this injury? (SBQ17SE.3) Proximal phalanx extraarticular fractures, Middle phalanx dorsal and palmar lip fractures (pilon). Fracture of the toe bones are mainly caused by different types of injuries, such as stubbing one or more toes or foot, dropping weighty objects on the toes etc. When associated with a crush injury, open fracture is more likely. Referral is recommended for patients with first-toe fracture-dislocations, displaced intra-articular fractures, and unstable displaced fractures (i.e., fractures that spontaneously displace when traction is released following reduction). 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. Correction of any clinically evident angulation is a key part of Emergency Department Management. The most common phalanx fractures involve the border digits, namely, the index and small finger rays (Fig. Such an injury in the great toe has not been reported previously in the English orthopaedic literature to our knowledge. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. 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 toe are one of the most common lower extremity fractures diagnosed by family physicians. Operative repair of the Lisfranc fracture. and S. Hacking, Evaluation and management of toe fractures. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. A radiograph is provided in Figure A. The Proximal Phalanx Bones Stock . Stable, reduced phalanx fractures are immobilized but require close monitoring to ensure maintenance of fracture reduction. Most commonly, the fifth metatarsal fractures through the base of the bone. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) Impacted fracture of the second toe proximal phalanx. According to two reviews of orthopedic management in the primary care setting , broken toes account for approximately 9 percent of fractures treated [ 1,2 ]. This page will discuss ankle and foot fractures and the role that physiotherapists play in the rehabilitation of such injuries. 1. This fracture causes one side of the bone to bend, but does. If an acute subungual hematoma is present (less than 24 hours old), decompression may relieve pain substantially. While celebrating the historic victory, he noticed his finger was deformed and painful. We help you diagnose your Toe fractures case and provide detailed descriptions of how to manage this and hundreds of other pathologies. A 34-year-old male sustains the closed finger injury shown in Figure A one week ago. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Physical examination reveals marked tenderness to palpation. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. (Left) X-ray shows a Jones fracture at the base of the fifth metatarsal (arrow). Non-narcotic analgesics usually provide adequate pain relief. Wear supportive shoe until pain resolves (usually 3 weeks). Displaced fractures of the first toe generally are managed similarly to displaced fractures of the lesser toes. Fractures can also develop after repetitive activity, rather than a single injury. To minimize the possibility of future disability, the position of the bone fragments after reduction should be as close to anatomic as possible. A fifth metatarsal fracture is a common injury where the bone connecting your ankle to your little toe breaks. Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. He complains of pain and swelling. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. 24(7): p. 466-7. Foot Anatomy Arteries FA13 | Foot Anatomy, Arteries, Anatomy . The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). Vollman, D. and G.A. Protected weightbearing in a short leg cast with gradual return to sport, Foot and ankle taping with immediate return to sport, Open reduction internal fixation with a precontoured plate, Type in at least one full word to see suggestions list, 2022 California Orthopaedic Association Annual Meeting, Jones Fractures: What's In, What's Out? On exam, he is neurovascularly intact. All Rights Reserved. Because Jones fractures are located in an area with poor blood supply, they may take longer to heal. Fractures of the toes represent the most common foot fractures in the pediatric age group and may account for as many as 18% of pediatric foot fractures. Evaluation of foot pain and identification of associated problems. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. - Radiology: - SH Type I Frxs: - separation of epiphysis occurs thru hypertrophying layer of cartilage cells; - proliferating cells are intact, the epiphysis continues to grow; - if nutrient artery is intact healing occurs in 3 weeks; - frx is most common in distal phalanx, uncommon in middle and proximal digits; Which of the following is responsible for the apex palmar fracture deformity noted on the preoperative radiographs? A fracture is an interruption of the continuity of bone. However, overlying shadows often make the lateral view difficult to interpret (Figure 1, center). Phalanx fractures are the most common injuries in the body. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. 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. (OBQ11.40) Causes of pain in the hindfoot, midfoot, and forefoot. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. (OBQ07.24) Operative treatment of intra-articular fractures of the dorsal aspect of the distal phalanx of digits. (SH I fracture of distal phalanx with associated nailbed injury or avulsion of proximal nail plate from eponychium), Needs orthopaedic admission for removal of nail, irrigation, repair of nailbed +/- fracture reduction.