What are the potential complications associated with this injury? Where expectant management is appropriate, it is advised to keep the affected toe buddy taped for three weeks 11. They should be instructed to keep the child in firm-soled shoes, ideally close-toed. Where buddy taping is performed, the parent should observe the method in case re-application is required in the coming weeks (including placing cotton between the toes to prevent skin maceration) Wear supportive shoe until pain resolves (usually 3 weeks).ġ0. No follow up required if successfully reduced <5yrs discuss with local Orthopaedic team as reduction success rate may be affected by size of phalanxĬan typically be reduced and buddy taped, in ED (place some cotton between the toes to prevent skin maceration) Nondisplaced fractures of the other toes do not require specific follow-upĭisplaced fractures (or for any fractures involving the great toe) - Fracture clinic within 7 daysĬan be reduced in ED: buddy tape in place with gauze between the toes. Non displaced: Buddy tape toes and use firm soled shoe or walking boot (CAM) for 3 weeksĭisplaced: Can be reduced in ED then buddy taped and firm soled shoe: - discuss with Orthopedics if reduction is unsuccessful Needs orthopaedic admission for removal of nail, irrigation, repair of nailbed +/- fracture reduction.Ĭommence antibiotics (cefalexin or cefazolin first line)įractures through the growth plate (Salter-Harris I - IV) (SH I fracture of distal phalanx with associated nailbed injury or avulsion of proximal nail plate from eponychium) What is the usual ED management for this injury, and what follow-up is required?įractures of the big toe should be followed up in fracture clinic, due to its role at the end of the stance phase in the gait cycle Open Fractures require orthopaedic consultation, including where a significant nailbed injury is suspected (see Seymour fracture, above in point 4).ĩ.This is particularly true of the fifth toe as malunion will cause longer-term issues such as fitting into shoes. Significantly displaced or angulated fractures require reduction When is reduction (non-operative and operative) required? The angulated fracture will need reduction Figure 6: Undisplaced Salter-Harris II of fourth and fifth toesįigure 7 & 8: Salter-Harris IV and Salter-Harris III of great toe proximal phalanx. What do they look like on x-ray?įigure 1: Seymour Fracture of the Great Toe (SH I with associated Nail Plate displacement)įigure 2: Salter Harris III at base of distal phalanxįigure 3: Undisplaced distal phalanx fractureįigure 4 &5: Displaced and anbulated Salter-Harris II of 5th toe proximal phalanx, & undisplaced shaft fracture of 5th toe proximal phalanx. without X-ray) with management as below (ie simply buddy-tape the affected toe and wear firm-soled shoes for 3 weeks) 6. Note that where there is bruising and swelling of toe 2, 3, 4 or 5 but no significant deformity and no open wound, it may be reasonable to diagnose a fracture clinically (i.e. Plain film – dorsoplantar, oblique and lateral views should be ordered where there is a suspected open fracture, a suspected fracture with associated angulation, a nailbed injury, or for any fracture of the great (1st) toe. What radiological investigations should be ordered? Any nail avulsion or displacement out of eponychial fold may indicate a Seymour fracture (see below)ĥ. It is also important to check for significant nailbed injury. It is important to check for angulation/mal-alignment and for rotational deformity (the position of the nail plate will give a guide to this and compare with toes on the other foot) Joint hyperextension or hyperflexion, which can lead to spiral or avulsion fracturesįractured toes usually present with localised bruising and swelling.Crush injury caused by a heavy object falling on the foot or motor vehicle tyre running over foot.
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