Most children with fractures of the physis should be referred, but children with selected nondisplaced Salter-Harris types I and II fractures may be treated by family physicians. Displaced fractures of the first toe generally are managed similarly to displaced fractures of the lesser toes. Nondisplaced acute metatarsal shaft fractures generally heal well without complications. J Pediatr Orthop, 2001. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). He came to the ER at that point to be evaluated. The proximal phalanx is the toe bone that is closest to the metatarsals. Mounts, J., et al., Most frequently missed fractures in the emergency department. A proximal phalanx is a bone just above and below the ball of your foot. Others use a cast that fixates the wrist, metacarpophalangeal joint and proximal phalanx but allows movement of the interphalangeal joints. Content is updated monthly with systematic literature reviews and conferences. MB BULLETS Step 1 For 1st and 2nd Year Med Students. Phalangeal fractures are the most common foot fracture in children. Treatment Most broken toes can be treated without surgery. Phalanx Dislocations are common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP). A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. 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. 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. The fractures reviewed in this article are summarized in Table 1. In children, toe fractures may involve the physis (Figure 2). Most metatarsal fractures can be treated with an initial period of elevation and limited weight bearing. Management of Proximal Phalanx Fractures Management of Proximal Phalanx Fractures & Their Complications. Copyright 2023 American Academy of Family Physicians. (Left) X-ray shows a Jones fracture at the base of the fifth metatarsal (arrow). Surgical repair is indicated for patients with progressive and persistent symptoms who fail nonoperative management. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. The skin should be inspected for open wounds or significant injury that may lead to skin necrosis. If no healing has occurred at six to eight weeks, avoidance of weight-bearing activity should continue for another four weeks.2,6,20 Typical length of immobilization is six to 10 weeks, and healing time is typically up to 12 weeks. See permissionsforcopyrightquestions and/or permission requests. Continue to learn and join meaningful clinical discussions . stress fracture of the proximal phalanx MRI indications positive bone scan hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture abnormal radiographs persistent pain, swelling, weak toe push-off not recommended routinely findings will show disruption of volar plate The injured toe should be compared with the same toe on the other foot to detect rotational deformity, which can be done by comparing nail bed alignment. toe phalanx fracture orthobulletsdaniel casey ellie casey. A collegiate soccer player presents as a referral to your office after sustaining an injury to the right foot, which he describes as hyperdorsiflexion of the toes. 21(1): p. 31-4. 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. Patients typically present with varying signs and symptoms, the most common being pain and trouble with ambulation. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. These bones comprise 2 bones in the hindfoot (calcaneus, talus), [ 1, 2] 5 bones in the midfoot (navicular, cuboid, 3. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. 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. Hyperflexion or hyperextension injuries most commonly lead to spiral or avulsion fractures. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. Fractures of multiple phalanges are common (Figure 3). As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. In most cases, this is done by simply adjusting the direction of traction to correct any shortening, rotation, or malalignment. There are 3 phalanges in each toe except for the first toe, which usually has only 2. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. Copyright 2016 by the American Academy of Family Physicians. Patients with open toe fractures or fractures with overlying skin necrosis are at high risk for osteomyelitis. What is the optimal treatment for the proximal phalanx fracture shown in Figure A? For several days, it may be painful to bear weight on your injured toe. Proximal phalanx fractures - displaced or unstable If a proximal phalanx fracture is displaced or if the fracture pattern is unstable it is likely that surgery will be recommended. Recent studies have demonstrated that musculoskeletal ultrasonography and traditional radiography have comparable accuracy, sensitivity, and specificity in the diagnosis of foot and ankle fractures9,10 (Figure 1). She is active in ballet and her pain is exacerbated with push-off and en pointe maneuvers. Nondisplaced tuberosity avulsion fractures can generally be treated with compressive dressings (e.g., Ace bandage, Aircast; Figure 11), with initial follow-up in four to seven days.2,3,6 Weight bearing and range-of-motion exercises are allowed as tolerated. The use of musculoskeletal ultrasonography may be considered to diagnose subtle metatarsal fractures. Because it is the longest of the toe bones, it is the most likely to fracture. If the bone is out of place and your toe appears deformed, it may be necessary for your doctor to manipulate, or reduce, the fracture. 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. There is evidence that transitioning to a walking boot and then to a rigid-sole shoe (Figure 6) at four to six weeks, with progressive weight bearing as tolerated, results in improved functional outcomes compared with cast immobilization, with no differences in healing time or pain scores.12, Follow-up visits should occur every two to four weeks, with repeat radiography at four to six weeks to document healing.3,6 At six weeks, callus formation on radiography and lack of point tenderness generally signify adequate healing, after which immobilization can be discontinued.2,3,6. Tuberosity avulsion fractures are generally found in zone 1 and do not extend into the joint between the fourth and fifth metatarsal bases (Figures 7 and 9). If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. A walking cast with a toe platform may be necessary in active children and in patients with potentially unstable fractures of the first toe. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. Which of the following is true regarding open reduction and screw fixation of this injury? (Right) An intramedullary screw has been used to hold the bone in place while it heals. Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). 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 . This webinar will address key principles in the assessment and management of phalangeal fractures. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. This information is provided as an educational service and is not intended to serve as medical advice. Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon. The video will appear on the video dashboard once complete. (Left) The four parts of each metatarsal. Since the fragment is pulled away from the rest of the bone, this type of injury is called an avulsion fracture. Nail bed injury and neurovascular status should also be assessed. At the conclusion of treatment, radiographs should be repeated to document healing. Clin OrthopRelat Res, 2005(432): p. 107-15. Common presenting symptoms include bruising, swelling, and throbbing pain that worsens with a dependent position, although this type of pain also may occur with an isolated subungual hematoma. Follow-up radiographs may be taken three to six weeks after the injury, but they generally do not influence treatment and probably are not necessary in nondisplaced toe fractures. Physical examination reveals marked tenderness to palpation. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. In an analysis of 339 toe fractures, 95% involved less than 2 mm of displacement and all fractures were managed conservatively with good outcomes.25, The most common mechanisms of injury are axial loading (stubbing) or crush injury. ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. (SBQ17SE.89) 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. Transverse and short oblique proximal phalanx fractures generally are treated with Kirschner wires, although a stable short oblique transverse shaft fracture can be managed with an intrinsic plus splint. The patient notes worsening pain at the toe-off phase of gait. Taping may be necessary for up to six weeks if healing is slow or pain persists. Evidence has shown that, depending on symptoms, short leg walking boots are superior to short leg walking casts.18,19 Immobilization in a cast or boot is typically only needed for two weeks, with progressive ambulation and range of motion thereafter as tolerated. Three muscles, viz. Ulnar gutter splint/cast. Treatment typically includes surgery to replace the fractured bone with an artificial implant, or to install hardware and screws to hold the bone in place. Patients should be instructed to apply ice, elevate the foot above heart level, and use analgesics as needed. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Injury. Surgeons will learn to assess and evaluate phalangeal anatomy and fracture geometry. If it does not, rotational deformity should be suspected. Healing rates also vary considerably depending on the age of the patient and comorbidities. Healing time is typically four to six weeks. For athletes and other highly active persons, evidence shows earlier return to activity with surgical management; therefore, surgery is recommended.13,21,22 In contrast, patients treated with nonsurgical techniques should be counseled about longer healing time and the possibility that surgery may be needed despite conservative management.2,13,2022, Patients with fifth metatarsal tuberosity avulsion fractures should be referred to an orthopedist if there is more than 3 mm of displacement, if step-off is greater than 1 to 2 mm on the cuboid articular surface, or if a fragment includes more than 60% of the metatarsal-cuboid joint surface. An MRI is performed and selected cuts are shown in Figures B and C. What is this patients diagnosis? 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. 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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