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Phalangeal Injuries, Foot, Emergency Medicine

Basics

Description

- 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.

  • 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 tapingGauze padding between the taped toes to prevent skin breakdown
  • Displaced fractures:Closed reduction by digital block anesthesiaLongitudinal tractionBuddy taping or splintingHard-sole shoe, weight bearing as toleratedOral analgesics for painPain usually resolved by 2 " “3 wk
  • IP joint dislocations:Closed reduction by digital block anesthesiaLongitudinal traction with gentle downward pressure on distal phalanxBuddy tape to adjacent toeUnstable 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 toleratedOral analgesics for painPain usually resolved in 2 " “3 wk
  • Open fractures:Orthopedic consultationProphylactic 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 woundsCefazolin: 1 g IM/IV in ED (peds: 50 " “100 mg/kg IM/IV in ED) for open fracturesCephalexin 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)