Forefoot injuries

Last evidence check May 2011

fracture toe1

Forced abduction fracture - "night walker's toe"

fracture toe 2

Irreducible fracture-dislocation of PIP joint with entrapped flexor tendon

Although toe fractures are common, there are no substantial series in the literature. Instead, there are a number of case reports which point out some pitfalls in management. It is therefore only possible to state some apparent principles.

Most toe fractures are low-energy. A classical mechanism is forced abduction of a toe stubbed against an obstacle: the "night-walker's toe".

Residual malalignment is often well-tolerated. There are no evidence-based guidelines for the amount of deformity that can be accepted, so advice on reduction and stabilisation will depend on the clinician's estimate of the likelihood that the toe may not fit comfortably into shoes, or may rub on other toes. If so correction and stabilisation may be advised. Occasionally toe injuries are irreducible, usually because of soft-tissue interposition and open reduction is required (Yasuda et al 1990, Fugate et al 1991). Late symptomatic deformities are usually dealt with by adaptations of standard toe straightening procedures such as interphalangeal arthroplasty or fusion.

Acute mallet deformity, analogous to that in the finger, may occur in the toes and normally responds to splintage although fragments may not unite radiologically (Rapoff and Heiner 1999, Hennessy and Saxby 2001).

Physeal injuries in children may be difficult to detect and should be considered, as late deformity may be difficult to treat (Buch and Myerson 1995).

Distal toe infections may include injuries to the nailbed which may be troublesome and occasionally need formal repair. Such penetrating injuries to the toes may lead to chronic infection, as elsewhere, and need proper wound toilet with prophylaxis for tetanus and pyogenic infection (Kensinger et al 2001).

Anawareness of the risk of nail-bed injuries, physeal injuries and chronic infection is necessary in managing apparently minor distal toe injuries.