The patient has stubbed, hyperflexed, hyperextended, hyperabducted, or dropped a weight on a toe. He presents with pain, swelling, ecchymosis, and decreased range of motion (ROM) or point tenderness. There may or may not be any deformity. Often, after stubbing the toe, there is little discomfort and no deformity, but the toe appears purple, and the patient wants to be sure that the “toe is not broken.”
What To Do:
Examine the toe, particularly for lacerations that could become infected, subungual hematoma that may require drainage, prolonged capillary filling time in the injured or other toes that could indicate poor circulation, or decreased sensation in the injured or other toes that could indicate peripheral neuropathy and may interfere with healing. When a fracture exists, most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit (i.e., compressing the distal phalanx toward the foot). Most displaced or angulated fractures and dislocations present with a visible deformity.
Radiographs often are not essential but may be necessary to provide patient satisfaction and to detect open fractures, angulated fractures, and fractures of the great toe. They may have little effect on the initial treatment of closed nonangulated lesser toe injuries but may help predict the duration of pain and disability (e.g., fractures entering the joint space or Salter-Harris fractures greater than type I or II).
Adult patients who are simply worried about their “purple” toe, when there is little or no pain or swelling and there is no angulation, should be encouraged to forgo the unnecessary irradiation of their foot, because the treatment will be essentially the same whether or not a fracture is present. You can still give the autonomy of decision making to the patient by stating, “I’d be glad to order an x-ray if you still want it.”
With or without a radiograph, a bruise or a stable, nondisplaced fracture of one of the lesser toes should be treated with comfortable footwear, usually consisting of a semirigid-sole shoe to limit joint movement. They can use whatever footwear provides them with the greatest comfort and protection. Buddy taping (described next) can be offered to the patient if it provides any improvement in comfort; otherwise, it is an unnecessary inconvenience. If helpful, the patient may also take acetaminophen or over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), unless contraindicated.
Displaced or angulated phalangeal fractures must be reduced with linear traction after a digital block (see Appendix B) or injection of the fracture hematoma. Angulation can be further corrected by using a finger as a fulcrum to reverse the direction of the distal fragment. The broken toe should fall into its normal position when it is released after 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. If it does not, rotational deformity should be suspected and corrected by further manipulation. If any deformity persists, specialty referral is indicated.
Postreduction, splint the broken toe by taping it to an adjacent, nonaffected toe (buddy taping). Slide one thickness of gauze or Webril cotton pads between the two toes, and, using half-inch tape, bind the toes together. Give the patient additional padding and tape so that he may revise the splinting, and (if there is a fracture) advise him that he will require such immobilization for approximately 1 week, by which time there should be good callus formation around the fracture and less pain with motion. Inform the patient that he must keep the padding dry between his toes while they are taped together or the skin will become macerated and break down. If the toe required reduction, warn him not to separate his toes when replacing the padding.
Also recommend rest, elevation, and mild analgesic medication. A cane, crutches, or hard-soled shoe that minimizes toe flexion may also provide greater comfort. Let the patient know that, in many cases, a soft slipper or an old sneaker with the toe cut out may be more comfortable.
If the fracture is not of a phalanx but of the metatarsal, buddy taping is not effective.
Arrange for follow-up if the toe is not much better within 1 week. Orthopedic or podiatric referral is indicated in patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, displaced intra-articular fractures, or fractures of the first toe that are unstable or involve more than 25% of the joint surface.
Because of the first toe’s role in weight bearing, balance, and pedal motion, fractures of this toe require referral much more often than other toe fractures. Deformity, decreased range of motion, and degenerative joint disease in this toe can impair a patient’s functional ability.
What Not To Do:
Do not tape toes together without padding between them, unless the tape is changed frequently and the skin is dried thoroughly if it becomes wet. (A hair dryer works well.) Friction and wetness will otherwise macerate the interdigital skin.
Do not let the patient overdo ice, which should not be applied directly to skin and should not be used for more than 10 to 20 minutes per hour. It is questionable whether or not cryotherapy provides any benefit, and it should be used only if it reduces discomfort.
Do not overlook the possibility of acute gouty arthritis (severe pain in the first metatarsophalangeal [MTP] joint), which sometimes follows minor trauma after a delay of a few hours (see Chapter 114).
The first toe has only two phalanges; the second through the fifth toes generally have three, but the fifth toe sometimes can have only two. Sesamoid bones generally are present within flexor tendons in the first toe. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx.
The same mechanisms that produce toe fractures may cause a ligament sprain, contusion, dislocation, tendon injury, or other soft tissue injury. With a clinically significant injury, radiographs are often required to distinguish these injuries from toe fractures. Tendon injuries are uncommon in closed injuries of the toes.
If there is no toe fracture, the treatment is the same, but the pain, swelling, and ability to walk may improve in 3 days rather than 1 to 2 weeks.
Although patients call the emergency department or clinic wanting to know whether or not their toe may be broken, if there is no deformity, they can usually be managed adequately over the telephone and seen the next day.
Stress fractures can occur in toes. They typically involve the medial base of the proximal phalanx and usually occur in athletes. Stress fractures have a more insidious onset and may not be visible on radiographs for the first 2 to 4 weeks after the injury.
Turf toe is a hyperextension sprain of the first metatarsophalangeal (MTP) joint with resulting subluxation and damage to the joint capsule. Hyperflexion, valgus, and varus stress can also cause MTP injury. Classic signs and symptoms include pain located over the plantar and medial aspect of the first MTP joint with associated swelling and ecchymosis. More severe injuries will exhibit marked swelling, limited range of motion, and an antalgic gait. Radiographs should be obtained to rule out associated fractures and possible degenerative arthritis. Treatment should be individualized, depending on the severity of the injury. Mild sprains respond to supportive care, including elevation, compression, and acetaminophen or NSAIDs. Further hyperextension can be limited with stiff, solid footwear. Moderate sprains require additional immobilization with cast padding, Ace wrap, and use of a stiff cast boot. Early ROM and strengthening exercises should be advanced as symptoms permit. Severe injuries warrant complete immobilization, crutches, and NSAIDs (if tolerated), as well as narcotic analgesics (if needed) and specialist consultation.