Fractures of the toe represent the most common fracture of the forefoot.
Digital(toe) injuries most commonly occur from direct trauma. Axial force,
crushing, or joint hyperflexion can result in a phalangeal fracture. The
mechanism of injury can range from low-energy trauma to high- energy and
direct force impact. Forefoot fractures include a variety of clinical
presentations and require thorough evaluation. Injuries can involve the
phalanges of the hallux or lesser digits, crushing injuries of the nail unit, and soft
tissue and sesamoid injuries. One of the challenges in treating toe injuries is
determining whether conservative or surgical care is more appropriate to
restore function and avoid long-term sequelae of the injury.
The most common mechanism of injury of digital(toe) fractures is an abductory force
in a lesser digit fracture. The proximal phalanx is more commonly injured
because of the length of the bone compared with the other phalanges, but the
middle and distal phalanx of the lesser digits may also be affected depending on
the type of injury. The fracture typically occurs through the midshaft, and
displacement is rare. Angulation of the digit is more common secondary to the
pull of the intrinsic musculature.
Majority of phalangeal fractures demonstrate minimal displacement and can
be treated through nonsurgical measures. Toe splinting with a stiff-soled shoe
for 4 to 6 weeks is recommended. The hallux and fifth digit can be splinted
to the foot utilizing different taping techniques, while the second, third and
fourth digits may be splinted to one another to provide stability. Nondisplaced
phalangeal fractures do not require surgical intervention, unless there is
instability or intraarticular involvement. Displaced fractures require closed
reduction, followed by immobilization. For fractures that are not amenable to
closed reduction, or if closed reduction is not successful, percutaneous fixation
or open reduction and internal fixation is necessary. Fractures with
significant displacement, joint involvement, or instability require open reduction
and internal fixation. Surgical correction can be achieved through percutaneous
pinning, screw fixation, plate and screw fixation, or cerclage wire fixation.
Open fractures typically result from crush injuries and require immediate
attention and surgical management. Tetanus status must be evaluated, and
antibiotic management should be initiated at the time of injury. Debridement
and irrigation of the fracture site is essential to reducing infection. These
wounds require careful monitoring of the soft tissue envelope, as vascular
interruption can lead to further tissue necrosis and potential need for
amputation.
Nail bed involvement is frequently associated with digital fractures resulting
from direct trauma. Subungual hematoma may indicate a distal
phalangeal fracture, and 20% to 25 % of hallux injuries exhibiting a subungual
hematoma will also have a phalangeal fracture. Traumatic onycholysis can
occur if enough force is present. If there is exposure of an underlying
fracture, there is a risk of bacterial contamination causing osteomyelitis.
The amount of hematoma present can be used to dictate treatment. If structural
integrity of the nail is maintained and less than 25% of the nail exhibits signs of
subungual hematoma, a simple procedure to drain the hematoma through the
nail plate can be performed. This can be accomplished with a hand-held
cautery device. If the nail is loose or if there is greater involvement of the
underlying hematoma, total nail avulsion should be completed and the nail bed
should be inspected for a laceration.
Sesamoid fractures result from direct trauma to the plantar first metatarsal
head. Sport activities increase pressure to the plantar first metatarsal head and
can lead to an acute fracture of the sesamoid. The tibial sesamoid is more
commonly affected in acute injuries, and is most commonly seen as a transverse
fracture. It can be difficult to differentiate between a bipartite sesamoid and
a fracture. Patient history and physical examination findings are necessary to
correlate with radiographic images. Bipartite sesamoids demonstrate a
reticulated margin and often do not fit together perfectly.
Contralateral radiographs should be considered to rule out a bipartite sesamoid. Fractures
that do not demonstrate displacement are treated with immobilization of the
toe in plantar flexion for 4 to 6 weeks. In cases of displaced fractures of the
sesamoids, percutaneous fixation is the preferred treatment. Sesamoidectomy
is reserved for severe cases of recalcitrant pain when conservative care has
failed to resolve symptoms. There is a risk of deformity to the first
metatarsophalangeal joint following sesamoid excision, with hallux valgus
following tibial sesamoid excision and hallux varus following fibular sesamoid
excision.
Source :Trauma of the Foot and Ankle