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What is the optimal treatment for the proximal phalanx fracture shown in Figure A? Others use a cast that fixates the wrist, metacarpophalangeal joint and proximal phalanx but allows movement of the interphalangeal joints. Fractures of the talus include fractures of the neck, body, medial or lateral process, and osteochondral injuries. Patients usually cannot bear full weight and sometimes will ambulate only on the medial aspect of the foot. Returning to activities too soon can put you at risk for re-injury. Displaced fractures of the first toe generally are managed similarly to displaced fractures of the lesser toes. However, if you have fractured several metatarsals at the same time and your foot is deformed or unstable, you may need surgery. We help you diagnose your Hand Proximal phalanx case and provide detailed descriptions of how to manage this and hundreds of other pathologies. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. An avulsion fracture is also sometimes called a "ballerina fracture" or "dancer's fracture" because of the pointe position that ballet dancers assume when they are up on their toes. Metatarsal shaft fractures near the head or base of the first to fourth metatarsal with any degree of displacement or angulation are often associated with concomitant injuries and generally take longer to heal. J Pediatr Orthop, 2001. Toe fractures are one of the most common fractures diagnosed by primary care physicians. 2 ). The use of musculoskeletal ultrasonography may be considered to diagnose subtle metatarsal fractures. If it does not, rotational deformity should be suspected. Fractures of multiple phalanges are common (Figure 3). Percutaneous Reduction and Fixation of Displaced Phalangeal Neck Fractures in Children 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. Unlike an X-ray, there is no radiation with an MRI. ClinPediatr (Phila), 2011. Your doctor will take follow-up X-rays to make sure that the bone is properly aligned and healing. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. Some metatarsal fractures are stress fractures. If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. Thank you. Physicians should consider referring patients with fractures of the great toe that have any degree of displacement, angulation, or rotational deformity 6,24 (Figure 12). Referral also is recommended for children with first-toe fractures involving the physis.4 These injuries may require internal fixation. Hand (N Y). There are 3 phalanges in each toe except for the first toe, which usually has only 2. In many cases, a stress fracture cannot be seen until several weeks later when it has actually started to heal, and a type of healing bone called callus appears around the fracture site. Patients with circulatory compromise require emergency referral. Although adverse outcomes can occur with toe fractures,3 disability from displaced phalanx fractures is rare.5. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Initial follow-up should occur within one to two weeks, then every two to four weeks for a total healing time of four to six weeks.6,23,24 Radiographic follow-up in seven to 10 days is necessary for fractures that required reduction or that involve more than 25% of the joint.6, Indications for referral of toe fractures include a fracture-dislocation, displaced intra-articular fractures, nondisplaced intra-articular fractures involving more than 25% of the joint, and physis (growth plate) fractures. Indications. A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. Because it is the longest of the toe bones, it is the most likely to fracture. 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. Epidemiology Incidence A radiograph, bone scan, and MRI are found in Figures A-C, respectively. Data Sources: We searched the Cochrane database, Essential Evidence Plus, and PubMed from 1900 to the present, human studies only, using the key words foot fractures, metatarsal, toe, and phalanges fractures. X-rays. The most common symptoms of a fracture are pain and swelling. Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations (Figure 5), displaced intra-articular fractures, and fractures that are difficult to reduce. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. Abductor, interosseus, and adductor muscles insert at the proximal aspects of each proximal phalanx. The video will appear on the video dashboard once complete. 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. Foot phalanges. 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. After that, nonsurgical treatment options include six to eight weeks of short leg nonweight-bearing cast with radiographic follow-up to document healing at six to eight weeks.2,6,20 If evidence of healing is present (callus formation and lack of point tenderness) at that time, weight-bearing activity can progress gradually, along with physical therapy and rehabilitation. If stable, the patient can be transitioned to a short leg walking cast or boot3,6 (Figures 411 and 5). Acute fractures to the proximal fifth metatarsal bone: Development of classification and treatment recommendations based on the current evidence. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. 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. Epidemiology Incidence Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. Physical examination findings typically include tenderness to palpation, swelling, ecchymosis, and sometimes crepitation at the fracture site. 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. Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. Surgery is not often required. 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. Foot Ankle Int, 2015. Nondisplaced or minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts with less than 10 of angulation can be treated conservatively with a short leg walking boot, cast shoe, or elastic bandage, with progressive weight bearing as tolerated. 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. 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. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. In some cases, a Jones fracture may not heal at all, a condition called nonunion. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. Indications for referral of patients with first metatarsal fractures are different because the first metatarsal has a vital role in weight bearing and arch support. (OBQ18.111) Copyright 2023 Lineage Medical, Inc. All rights reserved. Follow-up should occur within three to five days to allow for reduction of soft tissue swelling. Management of Proximal Phalanx Fractures Management of Proximal Phalanx Fractures & Their Complications. The same mechanisms that produce toe fractures may cause a ligament sprain, contusion, dislocation, tendon injury, or other soft tissue injury. 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. Phalanx Dislocations are common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP). Physical examination should include assessment of capillary refill; delayed capillary refill may indicate circulatory compromise. A Jones fracture is a horizontal or transverse fracture at the base of the fifth metatarsal. A fracture that is not treated can lead to chronic foot pain and arthritis and affect your ability to walk. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. A walking cast with a toe platform may be necessary in active children and in patients with potentially unstable fractures of the first toe. Proximal hallux. Nondisplaced fractures usually are less apparent; however, most patients with toe fractures have point tenderness over the fracture site. All material on this website is protected by copyright. Follow-up/referral. Metatarsal shaft fractures most commonly occur as a result of twisting injuries of the foot with a static forefoot, or by excessive axial loading, falls from height, or direct trauma.2,3,6 Patients may have varying histories, ranging from an ill-defined fall to a remote injury with continued pain and trouble ambulating. Treatment typically includes surgery to replace the fractured bone with an artificial implant, or to install hardware and screws to hold the bone in place. See permissionsforcopyrightquestions and/or permission requests. Mounts, J., et al., Most frequently missed fractures in the emergency department. - See: Phalangeal Injury Menu: - Discussion: - fractures of the proximal phalanx are potentially the most disabling fractures in the hand; - direct blows tend to cause transverse or comminuted frx, where as twisting injury may cause oblique or spiral fracture; - proximal fragments are usually flexed by intrinsics while distal fragments are extended due to extrinsic compressive forces; Copyright 2023 Lineage Medical, Inc. All rights reserved. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) 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. Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). 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. If this maneuver produces sharp pain in a more proximal phalanx, it suggests a fracture in that phalanx. 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. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. A proximal phalanx is a bone just above and below the ball of your foot. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. Deformity of the digit should be noted; most displaced fractures and dislocations present with visible deformity. (Left) In this X-ray, a fracture in the proximal phalanx of the fifth toe (arrow) has caused the toe to become deformed. 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. The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). Patients have localized pain, swelling, and inability to bear weight on the. Bicondylar proximal phalanx fractures usually are treated with plate fixation. Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). 118(2): p. e273-8. This is called internal fixation. Radiographs often are required to distinguish these injuries from toe fractures. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. After anesthetizing the toe with ice or a digital block, the physician holds the tip of the toe, applies longitudinal traction, and manipulates the bone fragments into proper position. Adjuvant imaging techniques to analyze fracture geometry and plan implant placement, will be discussed in detail. Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures. See permissionsforcopyrightquestions and/or permission requests. 2012 Oct; 43 ( 10 ): 1626-32. doi: 10.1016/j.injury.2012.03.010. All the bones in the forefoot are designed to work together when you walk. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? 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). Comminution is common, especially with fractures of the distal phalanx. All Rights Reserved. Published studies suggest that family physicians can manage most toe fractures with good results.1,2. He came to the ER at that point to be evaluated. 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. Search dates: February and June 2015. 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. Copyright 2003 by the American Academy of Family Physicians. Referral is recommended for patients with first-toe fracture-dislocations, displaced intra-articular fractures, and unstable displaced fractures (i.e., fractures that spontaneously displace when traction is released following reduction). 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. Fractures of the toes and forefoot are quite common. Most broken toes can be treated without surgery. These bones comprise 2 bones in the hindfoot (calcaneus, talus), [ 1, 2] 5 bones in the midfoot (navicular, cuboid, 3. 11(2): p. 121-3. Taping may be necessary for up to six weeks if healing is slow or pain persists. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. Lightly wrap your foot in a soft compressive dressing. Fractures of the proximal phalanx of the hallux involving the epiphysis may be intra-articular. The fifth metatarsal is the long bone on the outside of your foot. Sesamoid bones generally are present within flexor tendons in the first toe (Figure 1, top) and are found less commonly in the flexor tendons of other toes. Examination of the metatarsals should include palpation of the metatarsal base, shaft, and head, as well as examination of the proximal tarsometatarsal and distal metatarsophalangeal joints. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. ORTHO BULLETS Orthopaedic Surgeons & Providers Foot fractures range widely in severity, prognosis, and treatment. The fractures reviewed in this article are summarized in Table 1. Metatarsal fractures usually heal in 6 to 8 weeks but may take longer. 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. 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. Ulnar gutter splint/cast. 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. A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. At the conclusion of treatment, radiographs should be repeated to document healing. Lgters TT, PMID: 22465516. Patients usually present with a painful, swollen, ecchymotic toe with variable deformity and gait disturbance. There is typically focal tenderness, swelling, and ecchymosis at the base of the fifth metatarsal. 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 talus has a head, constricted neck, and body. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. Plate fixation . and C.W. This content is owned by the AAFP. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. The Ottawa Ankle and Foot Rules should be applied when examining patients with suspected fractures of the proximal fifth metatarsal to help decide whether radiography is needed14 (Figure 815 ). On exam, he is neurovascularly intact. Which of the following acute fracture patterns would best be treated with open reduction and internal fixation? A fracture of the toe may result from a direct injury, such as dropping a heavy object on the front of your foot, or from accidentally kicking or running into a hard object. Patients should be instructed to apply ice, elevate the foot above heart level, and use analgesics as needed. Concerns with delayed healing and/or high activity demands may result in your doctor recommending surgery for an acute Jones fracture as well. Objective Evidence Your foot may become swollen and discolored after a fracture. Foot fractures are among the most common foot injuries evaluated by primary care physicians. Hyperflexion or hyperextension injuries most commonly lead to spiral or avulsion fractures. All rights reserved. This webinar will address key principles in the assessment and management of phalangeal fractures. If the bone is out of place, your toe will appear deformed. Most commonly, the fifth metatarsal fractures through the base of the bone. If there is a break in the skin near the fracture site, the wound should be examined carefully. protected weightbearing with crutches, with slow return to running. 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. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. 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. rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. If no healing has occurred at six to eight weeks, avoidance of weight-bearing activity should continue for another four weeks.2,6,20 Typical length of immobilization is six to 10 weeks, and healing time is typically up to 12 weeks. Clin J Sport Med, 2001. Pediatrics, 2006. This topic will review the evaluation and management of toe fractures in adults. Clin OrthopRelat Res, 2005(432): p. 107-15. Surgeons will learn to assess and evaluate phalangeal anatomy and fracture geometry. abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. Clinical Features Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. While celebrating the historic victory, he noticed his finger was deformed and painful. Turf Toe is a hyperextension injury to the plantar plate and sesamoid complex of the big toe metatarsophalangeal joint that most commonly occurs in contact athletic sports.