fractures of the head of the proximal phalanx. A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine. Note that the volar plate (VP) attachment is involved in the . Copyright 2023 Lineage Medical, Inc. All rights reserved. For acute metatarsal shaft fractures, indications for surgical referral include open fractures, fracture-dislocations, multiple metatarsal fractures, intra-articular fractures, and fractures of the second to fifth metatarsal shaft with at least 3 mm displacement or more than 10 angulation in the dorsoplantar plane. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). If the bone is out of place, your toe will appear deformed. Avertical Lachman test will show greater laxity compared to the contralateral side. The same mechanisms that produce toe fractures may cause a ligament sprain, contusion, dislocation, tendon injury, or other soft tissue injury. Hand (N Y). Toe fractures are one of the most common fractures diagnosed by primary care physicians. What is the most likely diagnosis? Bite The Bullet, He Needs Long Term Function: Be The Hated Person - Robert Anderson, MD. Ribbans, W.J., R. Natarajan, and S. Alavala, Pediatric foot fractures. Foot Ankle Int, 2015. Kay, R.M. Great toe fractures are treated with a short leg walking boot or cast with toe plate for two to three weeks, then a rigid-sole shoe for an additional three to four weeks. Physical examination should include assessment of capillary refill; delayed capillary refill may indicate circulatory compromise. Radiographic studies of a toe should include anteroposterior, lateral, and oblique views (Figure 1). Repeat radiography is indicated and should be obtained one week post-fracture if there was intra-articular involvement or if a reduction was required. The younger the child, the more . 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. Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. In children, toe fractures may involve the physis (Figure 2). Because of the first toe's role in weight bearing, balance, and pedal motion, fractures of this toe require referral much more often than other toe fractures. 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. Pediatr Emerg Care, 2008. Proximal phalanx (finger) fracture Contents 1 Background The flexor digitorum superficialis (FDS) inserts at the middle of the phalanx and can cause rotational deformity [1] Extensor tendons and interosseous muscles commonly causes volar angulation [1] Clinical Features Finger pain Differential Diagnosis Hand and Finger Fractures Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) Treatment is generally straightforward, with excellent outcomes. Copyright 2023 American Academy of Family Physicians. Petnehazy, T., et al., Fractures of the hallux in children. Thus, this article provides general healing ranges for each fracture. Patient examination; . The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). A fracture, or break, in any of these bones can be painful and impact how your foot functions. This joint sits between the proximal phalanx and a bone in the hand . The skin should be inspected for open fracture and if . Patients with circulatory compromise require emergency referral. 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. A radiograph, bone scan, and MRI are found in Figures A-C, respectively. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. Fractures of multiple phalanges are common (Figure 3). Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. All the bones in the forefoot are designed to work together when you walk. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. Differential Diagnosis The same mechanisms that produce toe fractures. 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. Metatarsal fractures usually heal in 6 to 8 weeks but may take longer. 2 ). He came to the ER at that point to be evaluated. Transverse and short oblique proximal phalanx fractures generally are treated with Kirschner wires, although a stable short oblique transverse shaft fracture can be managed with an intrinsic plus splint. During this time, it may be helpful to wear a wider than normal shoe. 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. Diagnosis is made with plain radiographs of the foot. The preferred splinting technique is to buddy tape the affected toe to an adjacent toe (Figure 7).4 Treatment should continue until point tenderness is resolved, usually at least three weeks (four weeks for fractures of the first toe). Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. Rotator Cuff and Shoulder Conditioning Program. Foot radiography is required if there is pain in the midfoot zone and any of the following: bone tenderness at point C (base of the fifth metatarsal) or D (navicular), or inability to bear weight immediately after the injury and at the time of examination.14 When used properly, the Ottawa Ankle and Foot Rules have a sensitivity of 99% and specificity of 58%, with a positive likelihood ratio of 2.4 and a negative likelihood ratio of 0.02 for detecting fractures. Diagnosis can be made clinically and are confirmed with orthogonal radiographs. What is the optimal treatment for the proximal phalanx fracture shown in Figure A? As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Am Fam Physician, 2003. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. Most fifth metatarsal fractures can be treated with weight bearing as tolerated, and immobilization in a cast or walking boot. (OBQ12.89) Physical examination reveals marked tenderness to palpation. Remodeling of the fracture callus generally produces an almost normal appearance of the bone over a matter of months (Figure 26-36). 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. All Rights Reserved. Taping may be necessary for up to six weeks if healing is slow or pain persists. A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. Some metatarsal fractures are stress fractures. If this maneuver produces sharp pain in a more proximal phalanx, it suggests a fracture in that phalanx. For several days, it may be painful to bear weight on your injured toe. While you are waiting to see your doctor, you should do the following: When you see your doctor, they will take a history to find out how your foot was injured and ask about your symptoms. Fractures of the toes and forefoot are quite common. The flexor and extensor tendons impart a longitudinal compression force, which can shorten the phalanx and extend the distal fragment [ 1 ]. Because Jones fractures are located in an area with poor blood supply, they may take longer to heal. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. toe phalanx fracture orthobulletsforeign birth registration ireland forum. Displaced fractures of the first toe generally are managed similarly to displaced fractures of the lesser toes. All Rights Reserved. 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). Epidemiology Incidence A fractured toe may become swollen, tender, and discolored. At the conclusion of treatment, radiographs should be repeated to document healing. The reduced fracture is splinted with buddy taping. These tendons may avulse small fragments of bone from the phalanges; they also can be injured when a toe is fractured. They typically involve the medial base of the proximal phalanx and usually occur in athletes. If the wound communicates with the fracture site, the patient should be referred. RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. Pediatrics, 2006. Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures (Figure 6).4. Great toe fractures are generally treated with a short leg walking cast with a toe plate (Figure 1311 ) that extends past the great toe or with a short leg walking boot for two to three weeks.6 After this time, and in the absence of significant symptoms, the patient can progress to buddy taping and use of a rigid-sole shoe for three to four weeks.6,23,24 Range-of-motion exercises can generally be initiated at four weeks. Narcotic analgesics may be necessary in patients with first-toe fractures, multiple fractures, or fractures requiring reduction. A fractured toe may become swollen, tender, and discolored. Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx, Intrinsic muscle fibrosis and intrinsic minus contracture, PIP joint volar plate attenuation and extensor tendon disruption, Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands, Flexor tendon disruption with associated overpull of the extensor mechanism. Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. ClinPediatr (Phila), 2011. Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively, High rates of post-operative infection are common, Open reduction via an approach through the nail bed leads to significant post-operative nail deformity, Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively, Type in at least one full word to see suggestions list, Management of Proximal Phalanx Fractures & Their Complications, Middle Finger, Proximal Phalangeal Head - Bicondylar Fracture - Fixation, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. (Right) The bones in the angled toe have been manipulated (reduced) back into place. Surgeons will learn to assess and evaluate phalangeal anatomy and fracture geometry. 11(2): p. 121-3. It is one of the most common fractures of the foot and has unique characteristics that make it more likely to require surgery. 2012 Oct; 43 ( 10 ): 1626-32. doi: 10.1016/j.injury.2012.03.010. from the American Academy of Orthopaedic Surgeons, Bruising or discoloration that extends to nearby parts of the foot. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. 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. High-impact activities like running can lead to stress fractures in the metatarsals. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. MB BULLETS Step 1 For 1st and 2nd Year Med Students. 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. Mounts, J., et al., Most frequently missed fractures in the emergency department. There are 3 phalanges in each toe except for the first toe, which usually has only 2. Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). To check proper alignment, radiographs should be taken immediately after reduction and again seven to 10 days after the injury (three to five days in children).4 In patients with potentially unstable or intra-articular fractures of the first toe, follow-up radiographs should be taken weekly for two or three weeks to monitor fracture position. Fractures in this area can occur anytime there is a break in the compact bone matrix that makes up the proximal phalanx. Stress fractures can occur in toes. abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. Radiographs are shown in Figure A. When this happens, surgery is often required. Phalanx Dislocations are common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP). Primary care physicians are often the first clinicians patients see for foot injuries, and fractures are among the most common foot injuries they evaluate.1 This article will highlight some common foot fractures that can be managed by primary care physicians. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Injury. Patients have localized pain, swelling, and inability to bear weight on the. CrossRef Google Scholar PubMed 7 DeVries, JG, Taefi, E, Bussewitz, BW, Hyer, CF, Lee, TH. On exam, he is neurovascularly intact. The localized tenderness of a contusion may mimic the point tenderness of a fracture. 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. Ulnar gutter splint/cast. This webinar will address key principles in the assessment and management of phalangeal fractures. Fractures of the lesser toes are four times as common as fractures of the first toe.3 Most toe fractures are nondisplaced or minimally displaced. 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. 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). 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. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. Metatarsal shaft fractures are initially treated with a posterior splint and avoidance of weight-bearing activities; subsequent treatment consists of a short leg walking cast or boot for four to six weeks. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. It ossifies from one center that appears during the sixth month of intrauterine life. 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. All rights reserved. All critical aspects of phalangeal fracture care will be discussed with pertinent case examples. MTP joint dislocations. Fractures of the proximal phalanx of the hallux involving the epiphysis may be intra-articular. This content is owned by the AAFP. 36(1)p. 60-3. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx (Figure 2). Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. Referral should be strongly considered for patients with nondisplaced intra-articular fractures involving more than 25 percent of the joint surface (Figure 4).4 These fractures may lose their position during follow-up. 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. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball.
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