How Many Trumpets Have Sounded 2021, Articles P

All critical aspects of phalangeal fracture care will be discussed with pertinent case examples. Foot fractures range widely in severity, prognosis, and treatment. 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. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) Early surgical management of a Jones fracture allows for an earlier return to activity than nonsurgical management and should be strongly considered for athletes or other highly active persons. 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. Patient examination; . Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures. As your pain subsides, however, you can begin to bear weight as you are comfortable. Pediatr Emerg Care, 2008. fractures of the head of the proximal phalanx. If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. ORTHO BULLETS Orthopaedic Surgeons & Providers Copyright 2023 Lineage Medical, Inc. All rights reserved. ClinPediatr (Phila), 2011. 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). Unless it is fairly subtle, rotational deformity should be corrected by further manipulation. 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. The proximal phalanx is the phalanx (toe bone) closest to the leg. 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). 2012 Oct; 43 ( 10 ): 1626-32. doi: 10.1016/j.injury.2012.03.010. Thompson, T.M., et al., Foot injuries associated with all-terrain vehicle use in children and adolescents. (SBQ17SE.3) 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. Tang, Pediatric foot fractures: evaluation and treatment. (SBQ17SE.89) If there is a break in the skin near the fracture site, the wound should be examined carefully. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. 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. Fractures can affect: Causes of lesser toe (phalangeal) fractures Trauma (generally something heavy landing on the toe or kicking an immovable object) Treatment of lesser toe (phalangeal) fractures Non-displaced fractures Copyright 2023 Lineage Medical, Inc. All rights reserved. This content is owned by the AAFP. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. Bite The Bullet, He Needs Long Term Function: Be The Hated Person - Robert Anderson, MD. If a fracture is present, it will typically be one of two types: a tuberosity avulsion fracture or a Jones fracture (i.e., proximal fifth metatarsal metadiaphyseal fracture). Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. Percutaneous Reduction and Fixation of Displaced Phalangeal Neck Fractures in Children Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head, Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach, Open reduction and lag screw fixation with 1.3mm screws through a radial approach, Placement of a 1.5-mm condylar blade plate through a radial approach, Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint. 36(1)p. 60-3. 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. Surgery is required in the case of an open fracture, when there is significant displacement, or instability after reduction. Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. Remodeling of the fracture callus generally produces an almost normal appearance of the bone over a matter of months (Figure 26-36). Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. 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. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Fractures of the proximal phalanx of the hallux involving the epiphysis may be intra-articular. Surgery is not often required. A radiograph, bone scan, and MRI are found in Figures A-C, respectively. 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. Clinical Features The "V" sign (arrow) indicates dorsal instability. Foot Ankle Int, 2015. Toe and forefoot fractures often result from trauma or direct injury to the bone. Follow-up visits should be scheduled every two weeks, and healing time varies from four to eight weeks.3,6 Follow-up radiography is typically required only at six to eight weeks to document healing, or earlier if the patient has persistent localized pain or continued painful ambulation at four weeks.2,3,6. Comminution is common, especially with fractures of the distal phalanx. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? These tendons may avulse small fragments of bone from the phalanges; they also can be injured when a toe is fractured. If an acute subungual hematoma is present (less than 24 hours old), decompression may relieve pain substantially. 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. In most cases, a fracture will heal with rest and a change in activities. Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. 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! Patients usually present with a painful, swollen, ecchymotic toe with variable deformity and gait disturbance. It ossifies from one center that appears during the sixth month of intrauterine life. See permissionsforcopyrightquestions and/or permission requests. It is one of the most common fractures of the foot and has unique characteristics that make it more likely to require surgery. 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. 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. Rotator Cuff and Shoulder Conditioning Program. 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. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. The nail should be inspected for subungual hematomas and other nail injuries. Minimally displaced (less than 3 mm) avulsion fractures typically require immobilization and support with a short leg walking boot. Hatch, R.L. The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). If you experience any pain, however, you should stop your activity and notify your doctor. This usually occurs from an injury where the foot and ankle are twisted downward and inward. Because it is the longest of the toe bones, it is the most likely to fracture. 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.