Note that where there is bruising and swelling of toe 2, 3, 4 or 5 but no significant deformity and no open wound, it may be reasonable to diagnose a fracture clinically (i.e. Common mechanisms of injury include: Axial loading (stubbing toe) Abduction injury, often involving the 5th digit Crush injury caused by a heavy object falling on the foot or motor vehicle tyre running over foot Less common mechanism: Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon. Click the above link to see POSNA's latest updates! Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. This Guideline is for fractures of the phalanges of the ulnar four digits (index, middle, ring and little fingers). Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Which of the following is true regarding open reduction and screw fixation of this injury? He was initially treated with a short leg splint, non-weight bearing and elevation. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. Thank you. Fractured toes usually present with localised bruising and swelling. If an acute subungual hematoma is present (less than 24 hours old), decompression may relieve pain substantially. A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. [1]Treatment for a Boxer's fracture varies based on whether the fracture is open or closed, characteristics of the fracture . (Left) In this X-ray, a recent stress fracture in the third metatarsal is barely visible (arrow). A radiograph is provided in Figure A. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Physical exam shows swelling of the digit with no breaks in the skin, and no active flexion. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. A walking cast with a toe platform may be necessary in active children and in patients with potentially unstable fractures of the first toe. We help you diagnose your Toe fractures case and provide detailed descriptions of how to manage this and hundreds of other pathologies. Taping may be necessary for up to six weeks if healing is slow or pain persists. Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury. Patients with intra-articular fractures are more likely to develop long-term complications. Epidemiology Incidence Fractures can also develop after repetitive activity, rather than a single injury. 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). This webinar will address key principles in the assessment and management of phalangeal fractures. Phalanx fractures are the most common injuries in the body. The fifth metatarsal is the long bone on the outside of your foot. Radiopaedia.org, the wiki-based collaborative Radiology resource Irrigate wound A radiograph, bone scan, and MRI are found in Figures A-C, respectively. He states he has a 30-year-old lumberjack who earlier today was playing softball in the county championship when he slid into home plate in the bottom of the 9th inning. 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. 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. Operative repair of the Lisfranc fracture. Referral should be strongly considered for patients with nondisplaced intra-articular fractures involving more than 25 percent of the joint surface (Figure 4).4 These fractures may lose their position during follow-up. hand anatomy ligament injuries phalanx wrist collateral pip joint volar ligaments pipj accessory proper orthobullets surgery joints soft choose plasticsurgerykey. Displaced: Can be reduced in ED then buddy taped and firm soled shoe: - discuss with Orthopedics if reduction is unsuccessful, Nondisplaced fractures of the other toes do not require specific follow-up, Displaced fractures (or for any fractures involving the great toe) - Fracture clinic within 7 days. Copyright 2003 by the American Academy of Family Physicians. Case Discussion On examination, nail was separated from the nail bed with a small nail bed laceration. Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. Fractures of the toes and forefoot are quite common. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx (Figure 2). 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 Epidemiology Incidence A 20-year-old male collegiate basketball player presents with a 1 day history of left foot pain. A 28-year-old male injures his hand while playing basketball and presents to the emergency room. They represent > 50% of all phalangeal fractures and frequently involve the ungual tuft 1. The skin should be inspected for open fracture and if . A 19-year-old college soccer player has been experiencing pain along the lateral border of her foot since the beginning of the season 6 weeks ago. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. Correction of any clinically evident angulation is a key part of Emergency Department Management. While celebrating the historic victory, he noticed his finger was deformed and painful. (OBQ05.226) Open fractures require immediate IV antibiotics and urgent surgical washout. torus fracture plastic deformation Complete fractures Fracture location and pattern proximal-third, middle-third, distal-third apex volar or apex dorsal pattern Presentation Symptoms forearm pain and . He complains of immediate pain and is unable to finish the game. Treatment principles for proximal and middle . Finger injuries are a very common reason for children to present to an Emergency Department. Kannus et al. Pediatrics, 2006. This is called a "stress fracture.". As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. A 27-year-old man falls on his hand at work. . The appropriate treatment depends on the location of the fracture, the amount of displacement (shifting of the two ends of the fracture), and activity level of the patient. Surgery may be delayed for several days to allow the swelling in your foot to go down. A radiograph of her foot is found in Figure A. 2. (OBQ11.63) Foot and Toe Fractures Hindfoot Talus fracture Calcaneus fracture Midfoot Lisfranc injury Navicular fracture Cuboid fracture Cuneiform fracture Forefoot Fifth metatarsal fracture usually associated with distal phalanx fractures, comprised of proper and accessory collateral ligaments, both originate from middle phalanx condyles, proper collateral ligament inserts on volar base of distal phalanx, accessory collateral ligament inserts on volar plate, act as restraint against radial and ulnar deviation, both originate from proximal phalanx condyles, proper collateral ligament inserts on volar base of middle phalanx, forms 2 checkrein ligaments proximally that attach to proximal phalanx, skin puckering may indicate interposition of soft tissues within the joint, important to assess stability of the joint after reduction, perform with joint in full extension and in 30 of flexion, assesses competency of collateral ligaments when stressed in flexion, collateral ligament injury can be classified into 3 grades, grade II - laxity with firm endpoint and stable arc of motion, grade III - gross instability with no endpoint, assesses competency of secondary stabilizers (bony anatomy, accessory collateral ligaments, volar plate) when stressed in extension, ability to achieve full ROM indicates stable joint, traction neuropraxia may occur due to stretching of adjacent digital nerves, diagnosis confirmed by history, physical exam, and radiographs, dorsal dislocations are more common than volar dislocations, results from PIPJ hyperextension with longitudinal compression (i.e. If irreducible, refer to Orthopaedics. He undergoes closed reduction and pinning shown in Figure B to correct alignment. A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine. Patients with circulatory compromise require emergency referral. fibula fracture orthobullets. Deformity, decreased range of motion, and degenerative joint disease in this toe can impair a patient's functional ability. Can be reduced in ED: buddy tape in place with gauze between the toes. As your pain subsides, however, you can begin to bear weight as you are comfortable. Unlike an X-ray, there is no radiation with an MRI. Absence of adjunctive ultrasound stimulator use, Return to play prior to radiographic union. The olecranon bone graft was found to be safe and easy to harvest. 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. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. from the American Academy of Orthopaedic Surgeons, Bruising or discoloration that extends to nearby parts of the foot. Of these, over 60 to 75 percent involve the smaller toes [ 3,4 ]. Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). (OBQ18.111) Close inspection of the small bones in the hands and feet is important, particularly when in an examination setting! Stable, reduced phalanx fractures are immobilized but require close monitoring to ensure maintenance of fracture 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. Joint hyperextension, a less common mechanism, may cause spiral or avulsion fractures. 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). 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