ORTHO BULLETS Orthopaedic Surgeons & Providers A radiograph, bone scan, and MRI are found in Figures A-C, respectively. Vollman, D. and G.A. The proximal phalanx is the phalanx (toe bone) closest to the leg. Pediatrics, 2006. Objective Evidence Fractures in this area can occur anytime there is a break in the compact bone matrix that makes up the proximal phalanx. Published studies suggest that family physicians can manage most toe fractures with good results.1,2. This content is owned by the AAFP. A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Comminution is common, especially with fractures of the distal phalanx. Since the fragment is pulled away from the rest of the bone, this type of injury is called an avulsion fracture. Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. Your foot may become swollen and discolored after a fracture. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. 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. Fractures of the lesser toes are four times as common as fractures of the first toe.3 Most toe fractures are nondisplaced or minimally displaced. Management is determined by the location of the fracture and its effect on balance and weight bearing. Surgery may be delayed for several days to allow the swelling in your foot to go down. Patient examination; . A, Dorsal PIPJ fracture-dislocation. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow). . If it does not, rotational deformity should be suspected. Differential Diagnosis The same mechanisms that produce toe fractures. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, He Is Playing With Nonoperative Treatment - Michael Coughlin, MD, He Is Out! Phalangeal fractures are the most common foot fracture in children. Foot phalanges. Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury. 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. Others use a cast that fixates the wrist, metacarpophalangeal joint and proximal phalanx but allows movement of the interphalangeal joints. An AP radiograph is shown in FIgure A. 118(2): p. e273-8. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. 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). Follow-up should occur within three to five days to allow for reduction of soft tissue swelling. At the conclusion of treatment, radiographs should be repeated to document healing. (Left) X-ray shows a Jones fracture at the base of the fifth metatarsal (arrow). (Kay 2001) Complications: A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. 5th metatarsal most commonly fractured in adults, 1st metatarsal most commonly fractured in children less than 4 years old, 3rd metatarsal fractures rarely occur in isolation, 68% associated with fracture of 2nd or 4th metatarsal, peak incidence between 2nd and 5th decade of life, may have significant associated soft tissue injury, occurs with forefoot fixed and hindfoot or leg rotating, Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures, consider metabolic evaluation for fragility fracture, shape and function similar to metacarpals of the hand, first metatarsal has plantar crista that articulates with sesamoids, muscular balance between extrinsic and intrinsic muscles, Metatarsals have dense proximal and distal ligamentous attachments, 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with isolated fractures, implicated in formation of interdigital (Morton's) neuromas, multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to increased displacement, Classification of metatarsal fractures is descriptive and should include, look for antecedent pain when suspicious for stress fracture, foot alignment (neutral, cavovarus, planovalgus), focal areas or diffuse areas of tenderness, careful soft tissue evaluation with crush or high-energy injuries, evaluate for overlapping or malrotation with motion, semmes weinstein monofilament testing if suspicious for peripheral neuropathy, AP, lateral and oblique views of the foot, may be of use in periarticular injuries or to rule out Lisfranc injury, useful in detection of occult or stress fractures, second through fourth (central) metatarsals, non-displaced or minimally displaced fractures, evaluate for cavovarus foot with recurrent stress fractures, sagittal plane deformity more than 10 degrees, restore alignment to allow for normal force transmission across metatarsal heads, lag screws or mini fragment plates in length unstable fracture patterns, maintain proper length to minimize risk of transfer metatarsalgia, limited information available in literature, may lead to transfer metatarsalgia or plantar keratosis, treat with osteotomy to correct deformity, Majority of isolated metatarsal fractures heal with conservative management, Malunion may lead to transfer metatarsalgia, Posterior Tibial Tendon Insufficiency (PTTI). Thus, this article provides general healing ranges for each fracture. While you are waiting to see your doctor, you should do the following: When you see your doctor, they will take a history to find out how your foot was injured and ask about your symptoms. Am Fam Physician, 2003. The distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. toe phalanx fracture orthobullets Copyright 2016 by the American Academy of Family Physicians. The video will appear on the video dashboard once complete. The use of musculoskeletal ultrasonography may be considered to diagnose subtle metatarsal fractures. Diagnosis is made clinically with the inability to hyperextend the hallux MTP joint without significant pain and the inability to push off with the big toe. Thompson, T.M., et al., Foot injuries associated with all-terrain vehicle use in children and adolescents. Radiographs often are required to distinguish these injuries from toe fractures. Referral is indicated for patients with first metatarsal fractures with any displacement or angulation. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. Primary care physicians are often the first clinicians patients see for foot injuries, and fractures are among the most common foot injuries they evaluate.1 This article will highlight some common foot fractures that can be managed by primary care physicians. If this maneuver produces sharp pain in a more proximal phalanx, it suggests a fracture in that phalanx. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. Physicians should consider referring patients with fractures of the great toe that have any degree of displacement, angulation, or rotational deformity 6,24 (Figure 12). As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. Treatment is generally straightforward, with excellent outcomes. During the procedure, your doctor will make an incision in your foot, then insert pins or plates and screws to hold the bones in place while they heal. 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. Your doctor will then examine your foot and may compare it to the foot on the opposite side. Patients with these fractures should be referred to an orthopedist.2,3,6, The fifth metatarsal has the least cortical thickness of all the metatarsals.13 There are multiple strong ligamentous and capsular attachments surrounding the proximal fifth metatarsal; these allow stresses to be directed through this portion of the bone.13 Classically, fractures of the proximal fifth metatarsal can be classified based on anatomic location into one or more of three zones (Figure 7).3. Fracture position ideally will be maintained when traction is released, but in some cases the reduction can be held only with buddy taping. Metatarsal shaft fractures near the head or base of the first to fourth metatarsal with any degree of displacement or angulation are often associated with concomitant injuries and generally take longer to heal. 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. Content is updated monthly with systematic literature reviews and conferences. This webinar will address key principles in the assessment and management of phalangeal fractures. This webinar will address key principles in the assessment and management of phalangeal fractures. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. If an avulsion fracture results in a large displaced fracture fragment, however, your doctor may need to do an open reduction and internal fixation with plates and/or intramedullary screws. Patients usually cannot bear full weight and sometimes will ambulate only on the medial aspect of the foot. 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). This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. Adjuvant imaging techniques to analyze fracture geometry and plan implant placement, will be discussed in detail. Non-narcotic analgesics usually provide adequate pain relief. Diagnosis is made with plain radiographs of the foot. 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. (Left) In this X-ray, a fracture in the proximal phalanx of the fifth toe (arrow) has caused the toe to become deformed. Posterior splint; nonweight bearing; follow-up in three to five days, Short leg walking cast with toe plate or boot for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to six weeks, Open fractures; fracture-dislocations; intra-articular fractures; fractures with displacement or angulation, Short leg walking boot or cast for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to eight weeks, Open fractures; fracture-dislocations; multiple metatarsal fractures; displacement > 3 to 4 mm in the dorsoplantar plane; angulation > 10 in the dorsoplantar plane, Three-view foot series with attention to the oblique view, Compressive dressing; ambulate as tolerated; follow-up in four to seven days, Short leg walking boot for two weeks, with progressive mobility and range of motion as tolerated; follow-up every two to four weeks; healing time of four to eight weeks, Repeat radiography at six to eight weeks to document healing, Displacement > 3 mm; step-off > 1 to 2 mm on the cuboid articular surface; fracture fragment that includes > 60% of the metatarsal-cuboid joint surface, Short leg nonweight-bearing cast for six to eight weeks; cast removal and gradual weight bearing and activity if radiography shows healing at six to eight weeks, or continue immobilization for four more weeks if no evidence of healing; healing time of six to 12 weeks, Repeat radiography at one week for stability and at the six- to eight-week follow-up; if no healing at six to eight weeks, repeat radiography at the 10- to 12-week follow-up, Displacement > 2 mm; 12 weeks of conservative therapy ineffective with nonunion revealed on radiography; athletes or persons with high activity level, Three-view foot series or dedicated phalanx series, Short leg walking boot; ambulate as tolerated; follow-up in seven days, Short leg walking boot or cast with toe plate for two to three weeks, then may progress to rigid-sole shoe for additional three to four weeks; follow-up every two to four weeks; healing time of four to six weeks, Repeat radiography at one week if fracture is intra-articular or required reduction, Fracture-dislocations; displaced intra-articular fractures; nondisplaced intra-articular fractures involving > 25% of the joint; physis (growth plate) fractures, Buddy taping and rigid-sole shoe; ambulate as tolerated; follow-up in one to two weeks, Buddy taping and rigid-sole shoe for four to six weeks; follow-up every two to four weeks; healing time of four to six weeks, Displaced intra-articular fractures; angulation > 20 in dorsoplantar plane; angulation > 10 in the mediolateral plane; rotational deformity > 20; nondisplaced intra-articular fractures involving > 25% of the joint; physis fractures. Fractures of the toes and forefoot are quite common. 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: RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. In most cases, this is done by simply adjusting the direction of traction to correct any shortening, rotation, or malalignment. Other symptoms may include: If you think you have a fracture, it is important to see your doctor as soon as possible. The collateral ligaments and volar plate at the metacarpophalangeal (MCP) joint stabilize the proximal portion and the extensor tendon pulls the distal fragment into extension. 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. (SBQ17SE.89) Distal metaphyseal. These tendons may avulse small fragments of bone from the phalanges; they also can be injured when a toe is fractured. 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. Dislocation refers to displacement in which the two articular surfaces are no longer in contact, in contrast to subluxation, in which there is some contact (may be referred to as complete versus simple dislocation in some texts). High-impact activities like running can lead to stress fractures in the metatarsals. Which of the following is true regarding open reduction and screw fixation of this injury? Patients with circulatory compromise require emergency referral. After that, nonsurgical treatment options include six to eight weeks of short leg nonweight-bearing cast with radiographic follow-up to document healing at six to eight weeks.2,6,20 If evidence of healing is present (callus formation and lack of point tenderness) at that time, weight-bearing activity can progress gradually, along with physical therapy and rehabilitation. Copyright 2023 Lineage Medical, Inc. All rights reserved. CrossRef Google Scholar PubMed 7 DeVries, JG, Taefi, E, Bussewitz, BW, Hyer, CF, Lee, TH. 2017 Oct 01;:1558944717735947. Patients have localized pain, swelling, and inability to bear weight on the lateral aspect of the foot. Referral also is recommended for children with first-toe fractures involving the physis.4 These injuries may require internal fixation. J AmAcad Orthop Surg, 2001. Proximal articular. 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. All Rights Reserved. To enhance comfort, some patients prefer to cut out the part of the shoe that overlies the fractured toe. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. Plate fixation . The patient notes worsening pain at the toe-off phase of gait. In many cases, anteroposterior and oblique views are the most easily interpreted (Figure 1, top and bottom). Proximal hallux. Nondisplaced or minimally displaced (less than 2 mm) fractures of the lesser toes with less than 25% joint involvement and no angulation or rotation can be managed conservatively with buddy taping or a rigid-sole shoe. The next bone is called the proximal phalanx. However, overlying shadows often make the lateral view difficult to interpret (Figure 1, center). laceration bone talks, extensor tendon injuries hand orthobullets, flexor and extensor tendon injuries phoenix az arizona, tendon lacerations twin boro physical therapy, repair and rehabilitation of extensor hallucis longus and, extensor mechanism injury hip amp knee book, He came to the ER at that point to be evaluated. While on call at the local rural community hospital, you're called by an emergency medicine colleague. Pain is worsened with passive toe extension. Hand (N Y). Epub 2012 Mar 30. abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. See permissionsforcopyrightquestions and/or permission requests. When performed on 18 children with distal radius-ulna fractures, P_STAR achieved near anatomic fracture alignment with no nerve or tendon injury, infection, or refracture. Some metatarsal fractures are stress fractures. Copyright 2023 Lineage Medical, Inc. All rights reserved. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. This information is provided as an educational service and is not intended to serve as medical advice. Type in at least one full word to see suggestions list, 2022 California Orthopaedic Association Annual Meeting, COA Foot and Ankle End - Glenn Pfeffer, MD, Comminuted Fifth Metatarsal Fracture in 28M. Search dates: February and June 2015. Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). Patients typically present with varying signs and symptoms, the most common being pain and trouble with ambulation. Surgical fixation involves Kirchner wires or very small screws. For several days, it may be painful to bear weight on your injured toe. (OBQ05.209) Most metatarsal fractures can be treated with an initial period of elevation and limited weight bearing. Copyright 2023 Lineage Medical, Inc. All rights reserved. You will be given a local anesthetic to numb your foot, and your doctor will then manipulate the fracture back into place to straighten your toe. Indications. 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 percent of the joint surface. All Rights Reserved. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. 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. Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. The image shows a diagram of where these bones lie in the footthe midpoint of the proximal phalanges being where to the toes branch off from the main body of the foot. Copyright 2023 Lineage Medical, Inc. All rights reserved. While many Phalangeal fractures can be treated non-operatively, some do require surgery. rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. Toe fractures are one of the most common fractures diagnosed by primary care physicians. The flexor and extensor tendons impart a longitudinal compression force, which can shorten the phalanx and extend the distal fragment [ 1 ]. In children, toe fractures may involve the physis (Figure 2). Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. A fractured toe may become swollen, tender, and discolored. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Lgters TT, 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. Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx (Figure 2). Lesser toe fractures are about twice as common as great toe fractures.23,24 The great toe has an increased role in weight bearing and balance; thus, injury to the great toe is associated with higher morbidity.6,24, The primary goals of treating toe fractures include reestablishing and maintaining alignment, regaining range of motion, and preventing complications. ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. angel academy current affairs pdf . Great toe fractures are generally treated with a short leg walking cast with a toe plate (Figure 1311 ) that extends past the great toe or with a short leg walking boot for two to three weeks.6 After this time, and in the absence of significant symptoms, the patient can progress to buddy taping and use of a rigid-sole shoe for three to four weeks.6,23,24 Range-of-motion exercises can generally be initiated at four weeks. Avertical Lachman test will show greater laxity compared to the contralateral side. To check proper alignment, radiographs should be taken immediately after reduction and again seven to 10 days after the injury (three to five days in children).4 In patients with potentially unstable or intra-articular fractures of the first toe, follow-up radiographs should be taken weekly for two or three weeks to monitor fracture position.