Phalanx fractures are classified by the following: Phalangeal fractures are the most common foot fracture in children. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. Proximal articular. Patients with circulatory compromise require emergency referral. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. 2017, Management of Proximal Phalanx Fractures & Their Complications, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Proximal Phalanx Fracture: Case of the Week - Michael Firtha, DO, Proximal Phalanx Fracture Surgery by Dr. Thomas Trumble, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. 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. 3 Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. Metatarsal fractures usually heal in 6 to 8 weeks but may take longer. Minimally displaced (less than 3 mm) avulsion fractures typically require immobilization and support with a short leg walking boot. A radiograph, bone scan, and MRI are found in Figures A-C, respectively. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. 24(7): p. 466-7. 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. Bicondylar proximal phalanx fractures usually are treated with plate fixation. 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. 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. There should be at least three images of the affected toe, including anteroposterior, lateral, and oblique views, with visualization of the adjacent toes and of the joints above and below the suspected fracture location. These include metatarsal fractures, which account for 35% of foot fractures.2,3 About 80% of metatarsal fractures are nondisplaced or minimally displaced, which often makes conservative management appropriate.4 In adults and children older than five years, fractures of the fifth metatarsal are most common, followed by fractures of the third metatarsal.5 Toe fractures, the most common of all foot fractures, will also be discussed. 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). Copyright 2023 American Academy of Family Physicians. (OBQ12.89) To minimize the possibility of future disability, the position of the bone fragments after reduction should be as close to anatomic as possible. Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). Radiographs often are required to distinguish these injuries from toe fractures. Despite theoretic risks of converting the injury to an open fracture, decompression is recommended by most experts.5 Toenails should not be removed because they act as an external splint in patients with fractures of the distal phalanx. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. 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. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. A combination of anteroposterior and lateral views may be best to rule out displacement. The video will appear on the video dashboard once complete. A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. This webinar will address key principles in the assessment and management of phalangeal fractures. Although adverse outcomes can occur with toe fractures,3 disability from displaced phalanx fractures is rare.5. 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. Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. Thus, this article provides general healing ranges for each fracture. 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: Nail bed injury and neurovascular status should also be assessed. A, Dorsal PIPJ fracture-dislocation. 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. This usually occurs from an injury where the foot and ankle are twisted downward and inward. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. Lightly wrap your foot in a soft compressive dressing. In some practice sites, family physicians manage open toe fractures; a discussion about the management of this type of injury can be found elsewhere.3,4 Patients also may require referral because of delayed complications such as osteomyelitis from open fractures, persistent pain after healing, and malunion. This website also contains material copyrighted by third parties. 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. 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). 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. Surgical fixation involves Kirchner wires or very small screws. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. The use of musculoskeletal ultrasonography may be considered to diagnose subtle metatarsal fractures. If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. 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. Proximal hallux. After the splint is discontinued, the patient should begin gentle range-of-motion (ROM) exercises with the goal of achieving the same ROM as the same toe on the opposite foot. Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. Diagnosis is made with plain radiographs of the foot. Patients with open toe fractures or fractures with overlying skin necrosis are at high risk for osteomyelitis. Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) We help you diagnose your Toe fractures case and provide detailed descriptions of how to manage this and hundreds of other pathologies . Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) 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. Following 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. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. 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. 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. 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. A fracture, or break, in any of these bones can be painful and impact how your foot functions. Patients should be instructed to apply ice, elevate the foot above heart level, and use analgesics as needed. The nail should be inspected for subungual hematomas and other nail injuries. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. 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. Diagnosis can be made clinically and are confirmed with orthogonal radiographs. Some metatarsal fractures are stress fractures. Foot Ankle Int, 2015. About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an FAAOS Surgeon. Copyright 2003 by the American Academy of Family Physicians. As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. The "V" sign (arrow) indicates dorsal instability. Fractures in this area can occur anytime there is a break in the compact bone matrix that makes up the proximal phalanx. 68(12): p. 2413-8. 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. Comminution is common, especially with fractures of the distal phalanx. CrossRef Google Scholar PubMed 7 DeVries, JG, Taefi, E, Bussewitz, BW, Hyer, CF, Lee, TH. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. The same mechanisms that produce toe fractures may cause a ligament sprain, contusion, dislocation, tendon injury, or other soft tissue injury. (SBQ17SE.3) 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! Metacarpal Fractures Hand Orthobullets Fractures Of The Proximal Fifth Metatarsal Radiopaedia Fifth Metacarpal Fractures Statpearls Ncbi Bookshelf 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.
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