Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe to limit joint movement. Management of Proximal Phalanx Fractures Management of Proximal Phalanx Fractures & Their Complications. Initial management of a Jones fracture includes a posterior splint and avoidance of weight-bearing activity, with follow-up in three to five days. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. Copyright 2023 American Academy of Family Physicians. A fractured toe may become swollen, tender, and discolored. Copyright 2016 by the American Academy of Family Physicians. Proximal phalanx fractures often present with apex volar angulation. 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. Epidemiology Incidence A proximal phalanx is a bone just above and below the ball of your foot. A fracture that is not treated can lead to chronic foot pain and arthritis and affect your ability to walk. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. 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. 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. The "V" sign (arrow) indicates dorsal instability. J Pediatr Orthop, 2001. toe phalanx fracture orthobulletsdaniel casey ellie casey. Patient examination; . Open fractures, Infection, Compartment syndrome 3; References, Classification, Courses 3; Distal articular. What is the optimal treatment for the proximal phalanx fracture shown in Figure A? Fractures of the proximal phalanx of the hallux involving the epiphysis may be intra-articular. Advertisement Almost two-thirds of all bones in the feet belong to the toes; hence the risk of fracture in this part of the foot is much higher than the rest of the foot. 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. 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. Copyright 2003 by the American Academy of Family Physicians. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? Injuries to this bone may act differently than fractures of the other four metatarsals. Comminution is common, especially with fractures of the distal phalanx. Thus, this article provides general healing ranges for each fracture. Referral also is recommended for children with first-toe fractures involving the physis.4 These injuries may require internal fixation. 118(2): p. e273-8. And finally, the webinar will cover fixation techniques, including various instrumentation options.Moderator:Jeffrey Lawton, MDChief, Hand and Upper ExtremityProfessor, Orthopaedic SurgeryAssociate Chair for Quality and Safety, Orthopaedic SurgeryProfessor, Plastic SurgeryUniversity of MichiganAnn Arbor, MichiganFaculty: Charles Cassidy, MDHenry H. Banks Professor and ChairmanDepartment of OrthopaedicsTufts Medical CenterBoston, MassachusettsChaitanya Mudgal, MD, MS (Ortho), MChHand Surgery ServiceDepartment of OrthopedicsMassachusetts General HospitalChairman, AO NA Hand Education CommitteeAssociate Professor, Orthopedic Surgery, Harvard Medical SchoolBoston, MassachusettsAmit Gupta, MD, FRCSProfessorDepartment of Orthopaedic SurgeryUniversity of LouisvilleLouisville, KentuckyRebecca Neiduski, PhD, OTR/L, CHTDean of the School of Health SciencesProfessor of Health SciencesElon UniversityElon, North Carolina, Ring Finger Proximal Phalanx Fracture in 16M. What is the most likely diagnosis? This usually occurs from an injury where the foot and ankle are twisted downward and inward. Surgeons will learn to assess and evaluate phalangeal anatomy and fracture geometry. Pediatr Emerg Care, 2008. Patients with circulatory compromise require emergency referral. Radiographs are shown in Figure A. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. Kensinger, D.R., et al., The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx. (Kay 2001) Complications: This content is owned by the AAFP. Which of the following is responsible for the apex palmar fracture deformity noted on the preoperative radiographs? Approximately 10% of all fractures occur in the 26 bones of the foot. and C.W. Proximal hallux. All Rights Reserved. Therefore, phalanges and digits adjacent to the fracture must be examined carefully; joint surfaces also must be examined for intra-articular fractures (Figure 3). A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. Fractures in this area can occur anytime there is a break in the compact bone matrix that makes up the proximal phalanx. Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. 3 Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. Other symptoms may include: If you think you have a fracture, it is important to see your doctor as soon as possible. Fracture of the proximal phalanx of the little finger in children: a classification and a method to measure the deformity . The reduced fracture is splinted with buddy taping. Non-narcotic analgesics usually provide adequate pain relief. Minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts (Figure 2) and fractures with less than 10 of dorsoplantar angulation in the absence of other injuries can generally be managed in the same manner as nondisplaced fractures.24,6 Initial management includes immobilization in a posterior splint (Figure 311 ), use of crutches, and avoidance of weight-bearing activities. (Right) An intramedullary screw has been used to hold the bone in place while it heals. Most fifth metatarsal fractures can be treated with weight bearing as tolerated, and immobilization in a cast or walking boot. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. 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. Diagnosis is made with plain radiographs of the foot. Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Kay, R.M. 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. Foot fractures are among the most common foot injuries evaluated by primary care physicians. 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. She is active in ballet and her pain is exacerbated with push-off and en pointe maneuvers. The metatarsals are the long bones between your toes and the middle of your foot. A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. Spiral fractures often lead to rotation or shortening, and transverse fractures lead to angulation.6. If the wound communicates with the fracture site, the patient should be referred. All Rights Reserved. (Left) The four parts of each metatarsal. Patients with intra-articular fractures are more likely to develop long-term complications. A positive metatarsal loading test, which involves manual axial loading of the metatarsal, may exacerbate the pain and help differentiate a fracture from a soft tissue injury.3. The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). We help you diagnose your Hand Proximal phalanx case and provide detailed descriptions of how to manage this and hundreds of other pathologies. Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. Which of the following is true regarding open reduction and screw fixation of this injury? There are 3 phalanges in each toe except for the first toe, which usually has only 2. All rights reserved. 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. A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. More sensitive than an X-ray, an MRI can detect changes in the bone that may indicate a fracture. Your video is converting and might take a while Feel free to come back later to check on it. Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. Application of a gentle axial loading force distal to the injury (i.e., compressing the distal phalanx toward the foot) may distinguish contusions from fractures. They typically involve the medial base of the proximal phalanx and usually occur in athletes. Author disclosure: No relevant financial affiliations. Jones fractures are located in a watershed area for blood supply (zones 2 and 3) and have high rates of delayed union and nonunion17 (Figure 10). 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. Each metatarsal has the following four parts: Fractures can occur in any part of the metatarsal, but most often occur in the neck or shaft of the bone. Pain is worsened with passive toe extension. Clin OrthopRelat Res, 2005(432): p. 107-15. Ulnar side of hand. Patients typically present with pain, swelling, ecchymosis, and difficulty with ambulation. 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. Returning to activities too soon can put you at risk for re-injury. In children, toe fractures may involve the physis (Figure 2). Stress fractures are typically caused by repetitive activity or pressure on the forefoot. While many Phalangeal fractures can be treated non-operatively, some do require surgery. These rules have been validated in adults and children.16 If radiography is indicated, a standard foot series with anteroposterior, lateral, and oblique views is sufficient to make the diagnosis. Patients should be instructed to apply ice, elevate the foot above heart level, and use analgesics as needed. Tang, Pediatric foot fractures: evaluation and treatment. (Left) In this X-ray, a recent stress fracture in the third metatarsal is barely visible (arrow). Content is updated monthly with systematic literature reviews and conferences. All the bones in the forefoot are designed to work together when you walk. The proximal phalanx is the toe bone that is closest to the metatarsals. Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures (Figure 6).4. To unlock fragments, it may be necessary to exaggerate the deformity slightly as traction is applied or to manipulate the fragments with one hand while the other maintains traction. Foot fractures range widely in severity, prognosis, and treatment. The proximal phalanx is the phalanx (toe bone) closest to the leg. The fractures reviewed in this article are summarized in Table 1. 2017 Oct 01;:1558944717735947. The middle phalanx (P2) is dislocated or subluxated dorsally, and the volar lip is fractured at its base. Because it is the longest of the toe bones, it is the most likely to fracture. High-impact activities like running can lead to stress fractures in the metatarsals. Your foot may become swollen and discolored after a fracture. 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. Reduction of fractures in children can usually be accomplished by simple traction and manipulation; open reduction is indicated if a satisfactory alignment is not obtained. If an acute subungual hematoma is present (less than 24 hours old), decompression may relieve pain substantially. 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. Cessna 172 Propeller Overhaul Cost, Articles P