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. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. Because it is the longest of the toe bones, it is the most likely to fracture. In this type of injury, the tendon that attaches to the base of the fifth metatarsal may stretch and pull a fragment of bone away from the base. A Jones fracture is a horizontal or transverse fracture at the base of the fifth metatarsal. 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. Pediatric Foot Fractures : Clinical Orthopaedics and Related - LWW Open subtypes (3) Lesser toe fractures. All rights reserved. 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. Proximal Phalanx Fracture Toe Orthobullets: What They Are And Why You This usually occurs from an injury where the foot and ankle are twisted downward and inward. Copyright 2003 by the American Academy of Family Physicians. A fracture may also result if you accidentally hit the side of your foot on a piece of furniture on the ground and your toes are twisted or pulled sideways or in an awkward direction. Proximal Phalanx Fracture Management - PubMed 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. The Ottawa Ankle and Foot Rules should be used to help determine whether radiography is needed when evaluating patients with suspected fractures of the proximal fifth metatarsal. The reduced fracture is splinted with buddy taping. 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. 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. Your doctor will tell you when it is safe to resume activities and return to sports. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). 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. Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? Clinical Features A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. Proximal metaphyseal. The pull of these muscles occasionally exacerbates fracture displacement. This information is provided as an educational service and is not intended to serve as medical advice. Follow-up/referral. Foot Ankle Int, 2015. X-rays. A fifth metatarsal tuberosity avulsion fracture can be treated acutely with a compressive dressing, then the patient can be transitioned to a short leg walking boot for two weeks, with progressive mobility as tolerated after initial immobilization. J Pediatr Orthop, 2001. Displaced fractures of the first toe generally are managed similarly to displaced fractures of the lesser toes. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. A standard foot series with anteroposterior, lateral, and oblique views is sufficient to diagnose most metatarsal shaft fractures, although diagnostic accuracy depends on fracture subtlety and location.7,8 However, musculoskeletal ultrasonography can provide a quick bedside assessment without radiation exposure that accurately assesses overt and subtle nondisplaced fractures. Thank you. Surgical fixation involves Kirchner wires or very small screws. (Kay 2001) Complications: High-impact activities like running can lead to stress fractures in the metatarsals. Your next step in management should consist of: Percutaneous biopsy and referral to an orthopaedic oncologist, Walker boot application and evaluation for metabolic bone disease, Referral to an orthopaedic oncologist for limb salvage procedure, Internal fixation of the fracture and evaluation for metabolic bone disease, Metatarsal-cuneiform fusion of the Lisfranc joint. While many Phalangeal fractures can be treated non-operatively, some do require surgery. On exam, he is neurovascularly intact. fractures of the head of the proximal phalanx. Fracture of the proximal phalanx of the little finger in children: a classification and a method to measure the deformity . Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. Narcotic analgesics may be necessary in patients with first-toe fractures, multiple fractures, or fractures requiring reduction. Surgery is required in the case of an open fracture, when there is significant displacement, or instability after reduction. They typically involve the medial base of the proximal phalanx and usually occur in athletes. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website. Phalanx fractures are classified by the following: Phalangeal fractures are the most common foot fracture in children. Thus, this article provides general healing ranges for each fracture. Petnehazy, T., et al., Fractures of the hallux in children. Background: The goal of proximal phalangeal fracture management is to allow for fracture healing to occur in acceptable alignment while maintaining gliding motion of the extensor and flexor tendons. Abductor, interosseus, and adductor muscles insert at the proximal aspects of each proximal phalanx. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. 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. combination of force and joint positioning causes attenuation or tearing of the plantar capsular-ligamentous complex, tear to capsular-ligamentous-seasmoid complex, tear occurs off the proximal phalanx, not the metatarsal, cartilaginous injury or loose body in hallux MTP joint, articulation between MT and proximal phalanx, abductor hallucis attaches to medial sesamoid, adductor hallucis attaches to lateral sesamoid, attaches to the transverse head of adductor hallucis, flexor tendon sheath and deep transverse intermetatarsal ligament, mechanism of injury consistent with hyper-extension and axial loading of hallux MTP, inability to hyperextend the joint without significant symptoms, comparison of the sesamoid-to-joint distances, often does not show a dislocation of the great toe MTP joint because it is concentrically located on both radiographs, negative radiograph with persistent pain, swelling, weak toe push-off, hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture, persistent pain, swelling, weak toe push-off, used to rule out stress fracture of the proximal phalanx, nonoperative modalities indicated in most injuries (Grade I-III), taping not indicated in acute phase due to vascular compromise with swelling, stiff-sole shoe or rocker bottom sole to limit motion, more severe injuries may require walker boot or short leg cast for 2-6 weeks, progressive motion once the injury is stable, headless screw or suture repair of sesamoid fracture, joint synovitis or osteochondral defect often requires debridement or cheilectomy, abductor hallucis transfer may be required if plantar plate or flexor tendons cannot be restored, immediate post-operative non-weight bearing, treat with cheilectomy versus arthrodesis, depending on severity, Can be a devastating injury to the professional athlete, Posterior Tibial Tendon Insufficiency (PTTI). Treatment is generally straightforward, with excellent outcomes. Bite The Bullet, He Needs Long Term Function: Be The Hated Person - Robert Anderson, MD. Hand Proximal phalanx - AO Foundation We help you diagnose your Toe fractures case and provide detailed descriptions of how to manage this and hundreds of other pathologies . Fractures of multiple phalanges are common (Figure 3). Clinical Practice Guidelines : Toe Fractures - Royal Children's Hospital RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. 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. 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. Am Fam Physician, 2003. Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon. Nail bed injury and neurovascular status should also be assessed. Referral is indicated if buddy taping cannot maintain adequate reduction. protected weightbearing with crutches, with slow return to running. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. 68(12): p. 2413-8. Diagnosis and Management of Common Foot Fractures | AAFP This procedure is most often done in the doctor's office. 9(5): p. 308-19. Fractures of the talus include fractures of the neck, body, medial or lateral process, and osteochondral injuries. (OBQ18.111) Examination should consist of a neurovascular evaluation and palpation of the foot and ankle. Most patients with acute metatarsal fractures report symptoms of focal pain, swelling, and difficulty bearing weight. 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. Toe and Forefoot Fractures - OrthoInfo - AAOS Healing time is typically four to six weeks. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. (SBQ17SE.89) While many Phalangeal fractures can be treated non-operatively, some do require surgery. Foot phalanges - AO Foundation Most fractures can be seen on a routine X-ray. This is called internal fixation. Pediatric Phalanx Fractures. - Post - Orthobullets The fifth metatarsal is the long bone on the outside of your foot. 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. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. Although tendon injuries may accompany a toe fracture, they are uncommon. Epidemiology Incidence Tarsal phalanges fractures - OrthopaedicsOne Articles Which of the following is responsible for the apex palmar fracture deformity noted on the preoperative radiographs? Some metatarsal fractures are stress fractures. Management of Proximal Phalanx Fractures Management of Proximal Phalanx Fractures & Their Complications. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. All Rights Reserved. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. (OBQ05.209) 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. 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. If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx, Intrinsic muscle fibrosis and intrinsic minus contracture, PIP joint volar plate attenuation and extensor tendon disruption, Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands, Flexor tendon disruption with associated overpull of the extensor mechanism. A 55 year-old woman comes to you with 2 months of right foot pain. Copyright 2023 Lineage Medical, Inc. All rights reserved. Copyright 2023 American Academy of Family Physicians. Ulnar side of hand. Repeat radiography is indicated and should be obtained one week post-fracture if there was intra-articular involvement or if a reduction was required.