Basics
Description
- The phalanges of the foot are prone to injury.
- 5th (or small) toe most commonly affected
Etiology
- Usually the result of direct trauma
- Stubbing the toe, kicking a hard surface, or dropping a heavy object onto toes most common mechanisms of injury
Diagnosis
Signs and Symptoms
History
History may predict the type of injury found and should include: ‚
- Time of injury
- Mechanism
- History of previous trauma
- Status of tetanus immunization if laceration is present
Physical Exam
- Tenderness, swelling, crepitus, and ecchymosis of affected digit
- Subungual hematomas are often present.
- Lacerations or crush-type wounds
- Document neurovascular status of the affected digit.
Essential Workup
Radiographs of involved digit ‚
Diagnosis Tests & Interpretation
Imaging
- Radiographs of involved digit
- Lateral view may be most sensitive.
Differential Diagnosis
- Fracture
- Contusion
- Abrasion/laceration
- Dislocation
Treatment
Pre-Hospital
- Ice to affected digit
- Direct pressure and dressing to any wounds
Initial Stabilization/Therapy
- Ice to affected digit
- Direct pressure and dressing to any wounds
Ed Treatment/Procedures
- Fractures involving the proximal phalanx and interphalangeal (IP) joint of the hallux:
- Nondisplaced, non " “intra-articular fractures may be placed in a short-leg walking cast with toe extension for comfort.
- Displaced, non " “intra-articular fractures:
- Closed reduction with digital block anesthesia
- Longitudinal traction
- Placement in short-leg walking cast with toe extension:
- Intra-articular fractures of the hallux merit orthopedic consult:
- Frequently treated with open reduction and internal fixation
- Fractures involving the proximal phalanx and IP joint of the lesser toes:
- Rarely cause long-term disability
- Nondisplaced fractures:
- Treat with splinting or buddy taping
- Gauze padding between the taped toes to prevent skin breakdown
- Displaced fractures:
- Closed reduction by digital block anesthesia
- Longitudinal traction
- Buddy taping or splinting
- Hard-sole shoe, weight bearing as tolerated
- Oral analgesics for pain
- Pain usually resolved by 2 " “3 wk
- IP joint dislocations:
- Closed reduction by digital block anesthesia
- Longitudinal traction with gentle downward pressure on distal phalanx
- Buddy tape to adjacent toe
- Unstable or unsuccessful reductions require orthopedic consultation.
- Oral analgesics for pain
- Distal tuft fractures:
- Subungual hematomas should be drained.
- Nail-bed laceration repair may be necessary.
- Buddy tape digit to adjacent toe.
- Weight bearing as tolerated
- Oral analgesics for pain
- Pain usually resolved in 2 " “3 wk
- Open fractures:
- Orthopedic consultation
- Prophylactic antibiotics
Medication
- NSAIDs are useful in treating acute pain:
- Ibuprofen 800 mg (peds: 5 " “10 mg/kg) PO TID
- Narcotic analgesics may be required for severe pain
- Consider antibiotics for open wounds
- Cefazolin: 1 g IM/IV in ED (peds: 50 " “100 mg/kg IM/IV in ED) for open fractures
- Cephalexin 500 mg PO QID (peds 25 " “50 mg/kg/d in div. doses) for 7 days for dirty wounds.
Follow-Up
Disposition
Admission Criteria
- Unstable or blocked dislocations
- Open fractures require orthopedic consultation in the ED.
Discharge Criteria
All other fractures may be discharged with orthopedic follow-up in 2 " “3 wk to evaluate healing. ‚
Issues for Referral
Patient copies of any radiographs obtained may facilitate early follow-up. ‚
Follow-Up Recommendations
- Intra-articular fractures involving the proximal phalanx of the great toe require urgent orthopedic or foot and ankle surgery follow-up.
- Simple nondisplaced fractures of the small toes may often be followed by primary care physicians.
Pearls and Pitfalls
Open, displaced, or intra-articular fractures, particularly involving the hallux, merit orthopedic consultation. ‚
Additional Reading
- Ho ‚ K, Abu-Laban ‚ RB. Ankle and foot. In: Marx ‚ JA, ed. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby/Elsevier; 2010:670 " “697.
- Mittlmeier ‚ T, Haar ‚ P. Sesamoid and toe fractures. Injury. 2004;35(suppl 2):SB87 " “SB97.
- Schnaue-Constantouris ‚ EM, Birrer ‚ RB, Grisafi ‚ PJ, et al. Digital foot trauma: Emergency diagnosis and treatment. J Emerg Med. 2002;22:163 " “170.
- Wedmore ‚ IS, Charette ‚ J. Emergency department evaluation and treatment of ankle and foot injuries. Emerg Med Clin North Am. 2001;18:85 " “113.
Codes
ICD9
- 826.0 Closed fracture of one or more phalanges of foot
- 924.3 Contusion of toe
- 959.7 Knee, leg, ankle, and foot injury
- 893.0 Open wound of toe(s), without mention of complication
- 917.0 Abrasion or friction burn of foot and toe(s), without mention of infection
- 928.3 Crushing injury of toe(s)
ICD10
- S90.129A Contusion of unspecified lesser toe(s) without damage to nail, initial encounter
- S92.919A Unsp fracture of unsp toe(s), init for clos fx
- S99.929A Unspecified injury of unspecified foot, initial encounter
- S91.119A Laceration w/o fb of unsp toe w/o damage to nail, init
- S90.119A Contusion of unspecified great toe without damage to nail, initial encounter
- S90.413A Abrasion, unspecified great toe, initial encounter
- S90.416A Abrasion, unspecified lesser toe(s), initial encounter
- S92.403A Displaced unsp fracture of unsp great toe, init for clos fx
- S97.109A Crushing injury of unspecified toe(s), initial encounter
- S97.119A Crushing injury of unspecified great toe, initial encounter
- S97.129A Crushing injury of unspecified lesser toe(s), init encntr
SNOMED
- 282776008 Injury of toe (disorder)
- 58075000 Contusion of toe (disorder)
- 21351003 Fracture of phalanx of foot (disorder)
- 284552004 Laceration of toe (disorder)
- 17048005 Contusion of toenail (disorder)
- 211609000 Crush injury, toe(s) (disorder)
- 34283004 Abrasion and/or friction burn of toe without infection (disorder)