9/12/2023 0 Comments Non displaced toe fractureOther indications for referral (greater and lesser toes) include fracture dislocations and displaced intraarticular fractures. Referral is rarely necessary unless the fracture is open or difficult to reduce. Compared with the great toe, the lesser toes are extremely forgiving. Displaced intraarticular fractures of the great toe generally require internal fixation, as do great toe fractures that spontaneously become displaced when traction is released after reduction. Because deformity, decreased range of motion, and degenerative changes may interfere with patients’ activities, great toe fractures are much more likely than other toe fractures to require referral. The great toe plays an important weight-bearing role. Referral is preferable if the patient is diabetic or immunocompromised, the wound is grossly contaminated, or presentation is delayed. Open fractures of the distal phalanx should either be referred right away or treated promptly as described below. Open toe fractures involving the proximal phalanx should be referred promptly, as should severe crush injuries and those with vascular compromise. The proximal phalanx fracture also extends into the joint. Note that the distal phalanx fracture is comminuted with two separate fracture lines extending into the interphalangeal joint. Two phalanges are often fractured simultaneously, and intraarticular fractures are fairly common ( Figure 16-1 ).įracture of the great toe with involvement of proximal and distal phalanges. Toe fractures are frequently comminuted, particularly if the distal phalanx is involved. Spiral fractures may show shortening and rotation, and transverse fractures occasionally have significant angulation. Most toe fractures are nondisplaced or minimally displaced. The oblique view is often more helpful than the lateral because overlying shadows may make the lateral view difficult to interpret. In most cases, anteroposterior (AP), lateral, and oblique views are necessary to diagnose toe fractures. Not enough soft tissue exists to disguise the rotation, angulation, or shortening that accompanies most displaced toe fractures. Displaced toe fractures, on the other hand, are generally quite evident. The neurovascular status of the toes should be documented, although nerve or arterial injury associated with toe fractures is rare except with severe displacement and lawnmower-type injuries.īecause the bones are small and tenderness is generally diffuse, it is often difficult to pinpoint or confirm a nondisplaced toe fracture on clinical grounds alone. Significant crushing of overlying soft tissue and subsequent necrosis and sloughing may convert a closed fracture to an open one. In the case of the great toe, tense swelling may be apparent, particularly if a crushing injury has occurred. Injuries to the nail and nail plate are commonly associated with toe fractures, and a laceration of the nail plate often indicates an open fracture. Ecchymosis, a subungual hematoma, or both may be present. When examined, the fractured toe usually appears swollen, and point tenderness is present at the fracture site. A dull throbbing usually follows, however, and most patients who do not seek care initially do so after 24 to 48 hours. The severe pain experienced at the time of fracture often subsides, leading many patients to doubt the presence of a fracture. Open toe fractures are often caused by lawnmower injuries or other sharp trauma. Infrequently, hyperextension of the toe results in avulsion or spiral fractures. Nearly all toe fractures result from either a stubbing injury or a heavy object being dropped on the toe. Sesamoid bones may be present in the flexor tendons beneath the distal head of the metatarsals and are most frequently seen adjacent to the first metatarsal head. The action of these muscles occasionally contributes to displacement of proximal fragments. The interosseous, abductor, adductor, and flexor muscles insert at the bases of the proximal phalanges. These are occasionally injured in toe fractures. Extensor and flexor tendons insert on the proximal aspects of the middle and distal phalanges. The second through fifth digits generally have three phalanges, and the first toe (and occasionally the fifth) has two. In isolated settings, primary care physicians with additional experience in fracture management sometimes treat selected open toe fractures. Clinicians who understand basic principles of fracture care and can recognize the occasional toe fracture that requires referral should be able to confidently manage the vast majority of closed toe fractures. Hence, they are frequently managed by primary care providers. Toe fractures are relatively straightforward to treat, and the outcome is generally excellent. Toe fractures account for approximately 8% to 9% of fractures.
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