Phalangeal fractures are the most common fracture of the forefoot. The first and fifth toes are most commonly involved as these are the border digits.
The great toe has only a proximal and distal phalanx. The second through fifth toes have a proximal, middle and distal phalanx. Each phalanx consists of a proximal base, body and distal head. The middle and distal phalanges of the fifth digit are often fused.
Commonly, information regarding these fractures is conveyed with a descriptive classification denoting the phalanx (proximal, middle, distal), location within the bone, and the fracture pattern (transverse, oblique, spiral, comminuted).
The OTA classifies these fractures in the format (82()_ _ . _). The specific ray is denoted with an alphanumeric identifier. The letter denotes the ray (T-great toe, N- second toe, M- third toe, R- fourth toe, L-fifth toe). The number following the letter denotes the specific phalanx (1-proximal, 2-middle, 3-distal). The alpha subclassification represents the fracture pattern and the numeric subclassification represents the location within the bone.
Direct dorsal blows and "stub" injuries are the mechanisms are commonly responsible for phalangeal fractures of the forefoot. Direct dorsal blow injuries occur when an object falls onto the dorsal surface of the phalanges resulting in a crush injury. These result in transverse or comminuted fracture patterns. "Stub" injuries occur through an axial load applied along the axis of the phalanges and most often occur from walking barefoot or kicking heavy objects. These result in spiral or oblique fracture patterns. Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon.
Patients usually present with a painful, swollen, ecchymotic toe with variable deformity and gait disturbance. Physical examination reveals marked tenderness to palpation. The skin should be inspected for open fracture and if the distal phalanx is involved, the nail and nailbed should be inspected for damage.
AP, lateral and oblique radiographs of the toe involved are usually all that is necessary for diagnosis. Dental x-rays have been described for imaging the toes. As with other bones, suspected stress fracture may best be revealed with bone scan or MRI.
Most often these injuries are managed nonoperatively with modified shoewear for 2-3 weeks. Hard-sole shoes prevent pressure on the toes as the weight shifts onto the forefoot rocker during gait. The patient will often protect their weight bearing secondary to pain. Buddy taping may aid in comfort and alignment. These measures may be all that is needed for nondisplaced fractures.
Fractures with deformity require reduction and very unstable fractures or those with clinically significant deformity or articular involvement may require operative stabilization. Reduction and correction of angulation and rotation can be obtained through digital block and logintudinal traction. Finger traps may aid in gripping the toe and the nail bed can be used as a reference for alignment. Angular deformity can often be corrected by inserting a pen between the toes at the apex of the fracture to allow for a 3-point bend. Often buddy taping, alumafoam or a plaster splint are necessary to maintain reduction
Operative treatment is rarely indicated. This most often indicated for intra-articular fractures of the proximal phalanx of the great toe or multiple fractures of the toes in which alignment would be difficult to maintain due to lack of support from neighboring toes. Fixation often involves logintudinal insertion of a K-wire or mini-fragment screw across the IP joints to gain purchase in an intact phalanx or metatarsal. Ambulation is allowed as tolerated in a stiff soled shoe and the pins are removed at approximately 4 weeks.
Maluion can lead to residual deformity which in turn may lead to abnormal dorsal or plantar pressure causing discomfort with weight-bearing and shoe wear.
Red Flags and controversies
Seymour fracture or missed Seymour fracture in which the distal portion of the distal phalanx is fractured with an overlying nailbed injury. As in the hand, this is considered an open fracture and can lead to osteomyelitis of the distal phalanx. Prompt recognition with removal of the nail, irrigation, debridement and appropriate antibiotic prophylaxis can prevent infection.
There are no long term studies of the outcome of these fractures.