Toe fractures in adults

INTRODUCTION — Toe fractures are relatively common and frequently managed by primary care and emergency physicians. According to two reviews of orthopedic management in the primary care setting , broken toes account for approximately 9 percent of fractures treated [1,2]. Of these, over 60 to 75 percent involve the smaller toes [3,4]. Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. Treatment is generally straightforward, with excellent outcomes.

This topic will review the evaluation and management of toe fractures in adults. Toe fractures in children and other foot injuries and conditions are discussed separately:

●Fractures in children: (See "Metatarsal and toe fractures in children" and "Foot fractures (other than metatarsal or phalangeal) in children".)

●Fractures in adults: (See "Metatarsal shaft fractures" and "Proximal fifth metatarsal fractures" and "Stress fractures of the metatarsal shaft" and "Cuboid and cuneiform fractures" and "Non-stress fractures of the tarsal (foot) navicular".)

●Foot pain and other foot injuries: (See "Evaluation, diagnosis, and select management of common causes of forefoot pain in adults" and "Tarsometatarsal (Lisfranc) joint complex injuries" and "Running injuries of the lower extremities: Risk factors and prevention" and "Evaluation of the diabetic foot".)

CLINICAL ANATOMY — A detailed discussion of foot anatomy is provided separately. (See "Overview of foot anatomy and biomechanics and assessment of foot pain in adults", section on 'Anatomy and biomechanics'.)

By convention, toes and their respective metatarsals are numbered from one (great toe) through five (little toe). The second through fifth toes typically have three phalanges, while the great toe has two. Lesser toes, especially the fifth, may occasionally have only two phalanges (figure 1A-C).

Tendons and ligaments insert at the bases of each phalanx (figure 2 and figure 3 and figure 4 and figure 5). The forces exerted by these structures may contribute to displacement of fracture fragments. Tendons, joint capsule, or other soft tissues may sometimes become interposed between fracture fragments, rendering them irreducible except by an open surgical approach.

The plantar digital artery and nerve pass together along each side of each toe deep to the plantar surface (figure 6). Each toe also has a pair of dorsal digital arteries and nerves (figure 2 and figure 7). The dorsal neurovascular structures are generally smaller and less significant than the ones on the plantar surface, but there is some variation among individuals, particularly with the first (great) toe. It is unusual for the neurovascular bundle to be injured as a consequence of a toe fracture, unless the fracture is open (eg, lawnmower injuries) or caused by a serious crush injury.

MECHANISM OF INJURY — The most common causes of toe fractures are:

●Axial loading (eg, stubbing a toe)

●Abduction injury, classically involving the fifth digit with a "night-walker" fracture

●Crush injury from a falling object

Less commonly, joint hyperextension or hyperflexion can lead to spiral or avulsion fractures. Crush injuries are more likely to involve soft tissue and neurovascular damage [3,4].

CLINICAL PRESENTATION AND EXAMINATION — Patients usually present for evaluation because of pain, difficulty walking, or inability to fit comfortably into a shoe. In patients with sensory neuropathy (eg, due to diabetes), presentation may be delayed. (See "Evaluation of the diabetic foot".)

Ecchymosis and swelling are usually present and develop within the first few hours after injury. Palpation along the digit frequently reveals point tenderness at the fracture site. However, the toe is often diffusely swollen and tender, making it difficult to pinpoint the fracture location by examination alone.

With displaced fractures and dislocations, deformity of the toe is usually apparent. Rotational deformity is assessed by examining the orientation of the nail bed of the fractured toe. Rotational deformity is present if the nail bed does not lie in the same plane as that of the corresponding toe on the opposite foot [5].

In all cases, capillary refill should be assessed and the skin of the digit carefully inspected looking for lacerations and devitalized skin. Any wound should be carefully examined to rule out communication with the fracture site (ie, an open fracture). Devitalized skin may slough and convert a closed fracture into an open one. Injury to surrounding soft tissue including the nail and nail bed can occur, particularly with crush injuries. Subungual hematoma is often a marker of an underlying distal phalanx fracture [6]. Paronychia following minor trauma suggests fracture of the underlying phalanx; radiographs should be obtained in such circumstances [3]. (See "Subungual hematoma" and "Paronychia".)

DIAGNOSTIC IMAGING

Plain radiographs — Suspected phalangeal fractures and dislocations should be evaluated with plain radiographs, including anteroposterior, lateral, and oblique views (image 1A-C). The lateral view is often difficult to read due to overlying structures (image 1B). Non-displaced or minimally displaced fractures of the toes are common (image 2 and image 3 and image 4). Distal phalanx fractures, which often result from crush injuries (image 5), are common as well (image 6). Spiral fractures often demonstrate angulation, rotation, and shortening (image 7), and may be comminuted (image 8). Angulation and displacement may occur with transverse fractures (image 9), but these fractures are generally more stable.

Foot trauma often causes a fracture of more than one phalanx or toe (image 10). Therefore, it is important to read each radiograph systematically, and not to stop reading after the first fracture site is identified. Images of adjacent phalanges and toes should be carefully examined for evidence of fractures. Toe fractures are often comminuted (image 8), particularly those of distal phalanges (image 11). Intra-articular fractures are also relatively common (image 12 and image 10) and are at higher risk for long-term complications such as arthritis.

Ultrasound — Point-of-care musculoskeletal ultrasound (MSK US) is becoming a more widely used imaging modality for the diagnosis of fractures [7]. The highly reflective interface between bone and soft tissue enables the assessment of the most superficial bone contours, including toe phalanges [8]. Cortical discontinuities as small as 1 mm can be identified with high-resolution transducers [9], which allows for the diagnosis of occult fractures (ie, not visible on plain radiograph) at the bedside. Findings on MSK US that strongly suggest long bone fracture include:

●Cortical disruption (image 13)

●Edema (appears as hypoechoic bulge over injured cortex)

●Increased Doppler blood flow at fracture site (image 14)

The "cap" sign seen on transverse view is additional ultrasound evidence of fracture. This sign appears in the setting of cortical step-off and consists of a hyperechoic line that appears just above the curvilinear-appearing hyperechoic cortex (image 15).

Ultrasound examination of the foot is best completed with the patient supine, the sole of the foot placed on the examination table, and the ankle in slight plantar flexion (picture 1). A high-frequency (7 to 15 mHz) linear probe (38 mm in length) is essential when performing an ultrasound of the foot, but a smaller "hockey stick" linear probe (23 mm in length) (picture 2) makes examination of the toes easier [10]. When performing an ultrasound of the feet and toes, a standard two-position examination (longitudinal, or sagittal, view and transverse view) is performed. The cortex of each phalange is examined in the anterior-posterior plane looking carefully for any discontinuity in the hyperechoic surface (image 13). Occasionally, hematoma, edema, or ligamentous disruption may be seen (image 14).

Studies have not specifically evaluated the efficacy of ultrasound to diagnose fractures of the toes or distal phalanges, but results of studies of metatarsal fractures are suggestive [11,12]. In a prospective observational study of consecutive patients presenting to an emergency department with acute foot trauma, 88 patients with possible fifth metatarsal fracture were assessed with MSK US by an emergency physician and the results compared to plain radiographs read by an orthopedic surgeon (gold standard) [11]. Of the 33 fractures found by radiograph, 32 were also identified with MSK US. The diagnostic sensitivity of MSK US was 97.1 percent, specificity was 100 percent, the positive likelihood ratio was infinity, and the negative likelihood ratio was 0.03. In the hands of an experienced musculoskeletal ultrasonographer, it is likely that comparable results could be achieved for foot phalanx fractures.

DIAGNOSIS — The diagnosis of toe fractures is made by diagnostic imaging. In the large majority of cases, plain radiographs are sufficient. In rare cases, additional views or more advanced techniques may be needed to delineate concomitant injuries.

DIFFERENTIAL DIAGNOSIS — Toe fractures typically result from direct trauma to a digit and are readily diagnosed with plain radiographs. However, trauma may cause injuries other than fractures. In some cases, minor trauma may be incidental and toe pain may be due to an acute exacerbation of other, possibly chronic, conditions. Alternative diagnoses to consider include the following:

●Toe dislocation – A toe dislocation is usually obvious on examination, and results from a hyperextension or kicking injury. Plain radiographs establish the diagnosis and are important to obtain to evaluate for a concomitant fracture. (See "Digit dislocation reduction".)

●First metatarsophalangeal joint sprain (Turf toe) – "Turf toe" is caused by a forceful hyperextension of the great toe that damages the metatarsophalangeal (MTP) joint capsule and ligaments. Patients complain of pain at the plantar surface of the first MTP joint that increases with passive extension or resisted flexion of the great toe. Some degree of swelling, discoloration, and focal tenderness around the MTP is common. Plain radiographs are typically normal. (See "Evaluation, diagnosis, and select management of common causes of forefoot pain in adults", section on 'First metatarsophalangeal joint sprain ("turf toe")'.)

●Hallux rigidus (osteoarthritis of first toe) – Patients with hallux rigidus present with pain, stiffness, and if there has been recent trauma possibly swelling of the first MTP joint. Pain may be aggravated by walking or repetitive toe extension. Plain radiographs reveal loss of joint space at the first MTP joint and possibly osteophytes, but no fracture. (See "Evaluation, diagnosis, and select management of common causes of forefoot pain in adults", section on 'Hallux rigidus and hallux limitus'.)

●Gout – Attacks of gout involving the first MTP joint cause an acute onset of pain, swelling, and redness at the joint. Plain radiographs may reveal typical findings but no fracture. Definitive diagnosis requires synovial fluid analysis. (See "Clinical manifestations and diagnosis of gout".)

●Infection and osteomyelitis – Soft tissue infections involving a toe typically present as a painful, red, swollen digit, and may be unrelated to trauma. If not managed appropriately, such infections can lead to osteomyelitis. Fever, erythema, and warmth are generally not associated with toe fractures, although local discoloration can develop. No fracture is present on plain radiographs, although bony erosions and possibly periosteal elevation may be present if osteomyelitis has developed. (See "Nonvertebral osteomyelitis in adults: Clinical manifestations and diagnosis".)

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL — Referral is indicated for emergency conditions, most fractures involving the great toe, and some specific conditions associated with fractures of the lesser toes.

Emergency referral — Emergency conditions associated with toe fractures that require immediate referral to an orthopedist or podiatrist include [3,5]:

●Circulatory compromise

●Grossly contaminated wounds

●Open fractures of the proximal phalanx

Such injuries are usually trauma-related, perhaps involving a lawnmower, chainsaw, or heavy weight dropped on the toe, and often involve multiple digits. Patients who have sustained such injuries may have incurred other trauma as well and should be managed in accordance with the principles of advanced trauma life support (ATLS), including a thorough examination of the entire lower extremity. (See "Initial management of trauma in adults".)

General indications — Many non-displaced open fractures of the distal phalanx may be managed by primary care or emergency physicians, however, these injuries require close attention [13]. (See 'Treatment' below.)

If the clinician has minimal or no experience managing such fractures, it is perfectly acceptable to refer the patient to an orthopedist or podiatrist. This is especially true if the wound is contaminated or the patient is diabetic or otherwise immunocompromised. Any toe fracture that develops a complication, such as nonunion, osteomyelitis, or chronic pain, should be referred. (See "Evaluation of the diabetic foot" and "General principles of fracture management: Early and late complications", section on 'Nonunion and malunion' and "Nonvertebral osteomyelitis in adults: Clinical manifestations and diagnosis".)

Great toe fractures — Decreased function of the great toe can have a significant impact on a patient's life, given the toe's crucial role in balance and the toe-off phase of locomotion. Consequently, referral is more common for great toe fractures than for lesser toe fractures. Referral for management of great toe fractures should be made in the following circumstances [2]:

●Fracture with dislocation

●Displaced intraarticular fractures

●Unstable, displaced fractures (ie, fractures initially reduced that immediately displace once traction is released)

●Open fractures of the proximal phalanx

In addition, non-displaced intraarticular fractures that involve more than 25 percent of the joint space (image 16) are generally referred. These injuries may lead to degenerative joint disease, especially if anatomic position is lost before healing occurs.

Lesser toe fractures — Referral is rarely required for fractures of lesser toes (ie, toes other than the great toe). However, referral is indicated in the following situations:

●Displaced intraarticular fractures

●Irreducible fractures [14]

●Open fractures of non-distal phalanges (see 'Emergency referral' above)

●Fractures that do not maintain acceptable position with buddy taping

No guidelines defining acceptable fracture position have been published; clinicians must determine acceptability on the basis of clinical judgment, visual inspection, and radiograph appearance. Functional outcome is the most important criterion when making this decision. Excessive angulation or rotation in any direction can create pressure on the toe from an adjacent toe or shoe surface leading to pain and tissue breakdown.

Approximate radiographic guidelines for excessive angulation or rotation are as follow:

●More than 20 degrees of angulation in the dorsal-plantar (sagittal) plane

●More than 10 degrees of angulation in the medial-lateral (transverse) plane

●More than 20 degrees of rotational deformity

Referral is usually not necessary for non-displaced intraarticular fractures of the lesser toes, even if they involve more than 25 percent of the joint surface [5]. This approach is supported by the results of an observational study of 339 consecutive patients with toe fractures in which the outcome for the 122 patients (33 percent) with intraarticular fractures was identical to those with fractures not involving the joint [4].

TREATMENT — Treatment will vary according to the location and characteristics of the fracture.

Non-displaced fractures — Immobilization by taping the injured toe to the adjacent toe (buddy taping) is the appropriate initial management (picture 3). Some use a basket weave technique for added stability [3]. A piece of cotton or felt should be placed between the toes to avoid maceration. A rigid-soled shoe or postoperative (post-op) shoe (picture 4) aids in immobilization and comfort. Athletic and walking shoes provide inadequate immobilization, and their use is discouraged [3].

Patients with pain inadequately controlled with buddy taping, may require a walking boot or a short-leg walking cast with a toe plate (picture 5). The injured toe should be immobilized until point tenderness has resolved, which usually requires four to six weeks. An additional two to four weeks may be needed before patients can tolerate a tight-fitting dress shoe [3].

Application of ice and elevation of the foot above the level of the heart during the first few days after the injury will decrease inflammation, swelling, and pain. Care should be taken not to cause a cold-induced injury when applying ice. This can generally be accomplished by placing a layer of bandage or cloth between the ice and the skin, and limiting the application time to about 15 minutes at a time, followed by a respite of 20 to 30 minutes.

Nonsteroidal anti-inflammatories or acetaminophen are usually sufficient to control pain, although narcotic analgesics may be required for great toe fractures, multiple fractures, or displaced fractures requiring reduction. (See "General principles of acute fracture management".)

Injury to the nail bed — Nail bed injuries are seen frequently with distal phalanx fractures sustained from a fallen object. Subungual hematomas can cause severe pain, often indicate the presence of a distal phalanx fracture, and should be drained if seen within the first 24 hours [6]. Dorsal decompression of the hematoma may be performed using electrocautery, or possibly a scalpel. The toenail should be left in place because it provides additional support for the fracture. The management of subungual hematoma, including trephination techniques, is reviewed separately. (See "Subungual hematoma".)

Treatment of nail bed lacerations is controversial. Some recommend removing the nail to detect the presence of a laceration, if there is significant traumatic deformity of the nail or a sizable subungual hematoma [3,15,16]. They advocate laceration repair with absorbable sutures, following irrigation, if the wound is less than eight hours old [3]. The primary justification for this approach lies in the high correlation between nail bed injury and distal phalanx fracture, with the consequent risk of osteomyelitis associated with open fractures. Others, citing data showing no difference in outcome, advocate against removal of the nail and nail bed laceration repair [17,18]. We do not advocate routine toenail removal and nail bed laceration repair, and perform this procedure only when obvious malalignment of the nail bed laceration is present.

Displaced fractures — Many displaced toe fractures can be handled by non-specialists. The indications for orthopedic referral are outlined above. (See 'Indications for orthopedic consultation or referral' above.)

The goal of displaced fracture management is to achieve anatomic alignment with restoration of length and correction of rotational deformity. The toe should first be anesthetized by either the application of ice for 20 minutes or a digital nerve block. (See "Digital nerve block".)

Before the fracture is reduced, the clinician should briefly consider the major force involved in creating the injury. Reduction consists of moving the fracture fragments in the opposite direction of this force.

A pencil-sized object placed in the web space can provide stability and act as a fulcrum to facilitate reduction (figure 8) [3]. Reduction generally consists of distracting the fracture fragments, maintaining constant distraction while moving the fragments back into alignment, and holding the reduction in place until the injury is immobilized. If the fracture is not readily reduced, the deformity may need to be increased slightly before reattempting reduction. Irreducible fractures may have soft tissue interposed between fragments requiring open reduction in the operating room.

Following reduction, the orientation of the nail bed of the fractured toe should be compared with that of the corresponding toe on the opposite, uninjured foot to rule out uncorrected rotational deformity.

Reduced, stable fractures in lesser toes (ie, not the great toe) are supported by taping them to the adjacent toe (ie, buddy taping). Traction should be maintained on the injured lesser toe while buddy taping (picture 3) is performed. This approach usually provides adequate immobilization for lesser toe fractures following reduction. Some advocate a basket weave style of buddy taping for added stability [3].

After reduction of great toe fractures, traction should be released to determine stability. Stable fractures maintain their position after traction is released. If the fracture is stable, place the foot with the fracture in a walking cast with a toe plate (picture 5). This helps to reduce pain and decreases the risk of displacement. Great toe fractures that are unstable (ie, reduction is lost once traction is released) should be referred to a surgeon, as operative reduction and fixation may be necessary. Transverse fractures are more likely to be stable because they are better able to resist the deforming forces of muscular attachments. Oblique, spiral, and comminuted fractures are more likely to be unstable [3,19]. Post-reduction radiographs are recommended to assure acceptable alignment.

Open fractures — Complex open fractures should be referred. (See 'Indications for orthopedic consultation or referral' above.)

For simple open fractures involving the distal phalanx, thorough cleaning and irrigation with a large amount (approximately 150 mL or more) of isotonic saline through a syringe (ie, under pressure) is the most important component of management. The management of minor skin wounds in preparation for wound closure is reviewed in detail separately. (See "Minor wound evaluation and preparation for closure".)

As long as the wound is not grossly contaminated, skin edges may be loosely approximated using several sutures. Although research is limited, many physicians treat such wounds with prophylactic antibiotics against common skin bacteria for a few days. We suggest prophylactic antibiotics for at least 48 hours after injury, and if no signs of infection develop antibiotics may be discontinued. The use of antibiotic prophylaxis for all types of open fractures is reviewed separately. (See "Osteomyelitis associated with open fractures in adults", section on 'Antibiotics after open fracture'.)

Patients should be asked about tetanus immunization and appropriate treatment should be provided if they are inadequately immunized (table 1). Common signs of infection should be reviewed with the patient and they should be told to return if any such signs develop. (See "Tetanus".)

In settings where orthopedic referral is not readily available, primary care physicians are sometimes called upon to manage more complicated open toe fractures. A common scenario is a shear injury that partially or completely detaches the distal soft tissue, leaving bone exposed. The goal in such cases is to clean the wound and re-approximate the soft tissue so as to cover any visible bone. Such injuries may be managed as follows:

●Perform a digital block. (See "Digital nerve block".)

●Irrigate the wound with a large amount of isotonic saline (150 mL or more). (See "Minor wound evaluation and preparation for closure", section on 'Irrigation'.)

●Debride the wound of any visibly contaminated tissue. (See "Minor wound evaluation and preparation for closure", section on 'Debridement'.)

●Loosely close the soft tissue over the bone with a few sutures. (See "Skin laceration repair with sutures".)

Skin edges can be reapproximated, but it is common to leave soft tissue exposed to heal by secondary intention. If loosely sutured back into place, even completely avulsed flaps of skin may heal. If not, they at least provide a temporary physiologic dressing.

With some injuries, tissue loss is extensive and visible bone cannot be covered or bone fragments protrude. This may be managed by using a rongeur to remove small pieces of the bone a bit at a time until all visible bone can be covered by the remaining soft tissue. This procedure is typically well-tolerated provided the digital block is effective and only small pieces of bone are removed at a time.

Prophylactic antibiotics should be given and the patient instructed to be extremely conscientious about keeping the extremity elevated and seeking medical care immediately for any sign of infection. Ideally, wound checks are performed every two to three days until healing is well established. (See "Osteomyelitis associated with open fractures in adults", section on 'Antibiotics after open fracture'.)

FOLLOW-UP CARE

General guidelines — Immobilization with buddy-taping (picture 3) is generally recommended for four to six weeks after injury. Cast immobilization, if necessary, is maintained for two to three weeks, with subsequent buddy-taping continued for three to four weeks after cast removal. Follow-up examination and radiograph schedules vary according to the type of injury.

Closed injury — Initial follow-up should occur one to two weeks following a closed injury. Follow-up radiographs are not necessary in most patients; they are recommended every 7 to 10 days to assess alignment only for fractures that required reduction or extended into the joint. Close follow-up is particularly important for fractures of the great toe, as malalignment of this toe can have significant consequences. (See 'Complications' below.)

Open injury — Open injuries require more careful initial monitoring for signs of infection. Initial wound reassessment should take place three to five days after the injury. Sutures are removed and radiographs taken to evaluate for signs of osteomyelitis approximately 14 days after the injury. Thereafter, radiographs can be repeated every two weeks until the wound is healed, or sooner if the patient is symptomatic (eg, fever, focal erythema or discharge).

Post-immobilization — Gentle range of motion (ROM) exercises should begin once the toe is no longer immobilized. Comparing ROM of the toes on the affected and unaffected sides will help patients to assess their progress. Post-immobilization radiographs are usually unnecessary, unless the fracture involves the great toe, the patient does not improve as expected, or the patient continues to have pain and difficulty walking after the four to six-week recovery period [5]. The radiographic hallmark of healing is callus at the fracture site (image 17).

COMPLICATIONS — Complications from toe fractures are unusual. Degenerative changes can result from fractures involving the joint surfaces. This may lead to chronic pain and decreased activity. Malunion (ie, incomplete healing or healing of fragments in an unacceptable position) can cause similar morbidity. Achieving anatomic alignment of the great toe is especially important to avoid chronic pain and disability. There is little disability associated with degenerative changes or decreased range of motion in the lesser toes. Mild angulation of the lesser toes is usually well tolerated, unless friction occurs with an adjacent toe, the ground, or the top of a shoe. Osteomyelitis can occur after an open fracture, and neurovascular injuries are sometimes seen after crush injuries or lacerations. (See "General principles of fracture management: Early and late complications".)

RETURN TO WORK OR SPORTS — Patients with great toe fractures that are intraarticular, unstable, or potentially unstable should be discouraged from stressing the toe until the injury is healed (ie, point tenderness has resolved and callus is seen on follow-up radiographs) (image 17). For other toe fractures, patients should be encouraged to advance activities as their symptoms allow. Patients vary widely in the speed with which they resume regular activities. Immobilization for three to four additional weeks (ie, total period of immobilization seven to nine weeks) may be required in patients who plan to return to sports or other demanding physical activities.

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of definitive fracture management".)

●(See "General principles of acute fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lower extremity (excluding hip) fractures in adults" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Toe fracture (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Mechanism and presentation – Axial loading, abduction, and crush injury are the primary mechanisms for toe fracture. Patients typically present because of pain, difficulty walking, or inability to fit comfortably into a shoe. In patients with sensory neuropathy (eg, diabetes), presentation may be delayed. (See 'Mechanism of injury' above and 'Clinical presentation and examination' above.)

●Physical examination – Ecchymosis and swelling are usually present and develop within the first few hours after injury. Subungual hematoma is a common finding with distal toe fractures. Comparison of nail bed rotation between the injured and corresponding uninjured toe is useful to assess rotational deformity. All injuries should be assessed for neurovascular function and the presence of an open fracture. (See 'Clinical presentation and examination' above.)

●Diagnostic imaging – Standard radiographs should be obtained if a toe fracture is suspected. Many foot injuries involve fractures of more than one phalanx or toe. Thus, it is important to read each radiograph systematically searching for additional bony injuries. (See 'Diagnostic imaging' above.)

●Differential diagnosis – The differential diagnosis includes toe dislocation and sprain of the first metatarsophalangeal joint (ie, turf toe), either of which may involve a concomitant fracture, gout, and other conditions. (See 'Differential diagnosis' above.)

●Indications for surgical referral – Referral is indicated for emergency conditions (eg, multiple open or grossly contaminated fractures) and often for fractures involving the great toe. Fractures of the lesser toes typically do not need referral unless they are displaced and intraarticular or displaced and irreducible or an acceptable reduction cannot be maintained. Guidelines for acceptable fracture rotation or angulation of lesser toe fractures are provided in the text. (See 'Indications for orthopedic consultation or referral' above.)

●Management – Initial treatment varies according to the location and characteristics of the fracture. Many can be managed with basic immobilization. The goal when managing displaced fractures is to achieve anatomic alignment with restoration of length and correction of rotational deformity. Post-reduction assessment by radiograph and comparison with the corresponding uninjured toe is important. (See 'Treatment' above.)

●Follow-up care – Healing rates vary but generally range from four to six weeks. Follow-up examination and radiograph schedules vary according to the type of injury. Open injuries require close initial monitoring. (See 'Follow-up care' above.)

Patients with great toe fractures that are intraarticular, unstable, or potentially unstable should be discouraged from stressing the toe until there is clinical and radiographic evidence of healing. Patients planning to return to vigorous work or sporting activities may require longer immobilization. (See 'Return to work or sports' above.)

ACKNOWLEDGMENT — The authors thank Joni Jones, RT(R)(CT)(MR), Florida State University, for her invaluable assistance with the radiographic images.