The distal phalanx is the most common location for a non-physeal injury which typically involves a crushing mechanism, and the most common location for physeal injury is the proximal phalanx. - See: Phalangeal Injury Menu: - Discussion: - fractures of the proximal phalanx are potentially the most disabling fractures in the hand; - direct blows tend to cause transverse or comminuted frx, where as twisting injury may cause oblique or spiral fracture; - proximal fragments are usually flexed by intrinsics while distal fragments are extended due to extrinsic compressive forces; An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. Copyright 2016 by the American Academy of Family Physicians. Follow-up should occur within three to five days to allow for reduction of soft tissue swelling. In most cases, this is done by simply adjusting the direction of traction to correct any shortening, rotation, or malalignment. 2012 Oct; 43 ( 10 ): 1626-32. doi: 10.1016/j.injury.2012.03.010. A proximal phalanx is a bone just above and below the ball of your foot. These rules have been validated in adults and children.16 If radiography is indicated, a standard foot series with anteroposterior, lateral, and oblique views is sufficient to make the diagnosis. Phalanx Dislocations are common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP). Published studies suggest that family physicians can manage most toe fractures with good results.1,2. While celebrating the historic victory, he noticed his finger was deformed and painful. Patients have localized pain, swelling, and inability to bear weight on the. They typically involve the medial base of the proximal phalanx and usually occur in athletes. X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow). Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. Examination should consist of a neurovascular evaluation and palpation of the foot and ankle. 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). Deformity of the digit should be noted; most displaced fractures and dislocations present with visible deformity. Physical examination reveals marked tenderness to palpation. The patient notes worsening pain at the toe-off phase of gait. He states he has a 30-year-old lumberjack who earlier today was playing softball in the county championship when he slid into home plate in the bottom of the 9th inning. Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). Copyright 2023 Lineage Medical, Inc. All rights reserved. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Adjuvant imaging techniques to analyze fracture geometry and plan implant placement, will be discussed in detail. Which of the following is true regarding open reduction and screw fixation of this injury? Non-narcotic analgesics usually provide adequate pain relief. Nail bed injury and neurovascular status should also be assessed. A 19-year-old cross country runner complains of 3 months of foot pain with running. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. Referral is indicated for patients with first metatarsal fractures with any displacement or angulation. Stress fractures can occur in toes. Injury. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. Bicondylar proximal phalanx fractures usually are treated with plate fixation. The flexor and extensor tendons impart a longitudinal compression force, which can shorten the phalanx and extend the distal fragment [ 1 ]. stress fracture of the proximal phalanx MRI indications positive bone scan hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture abnormal radiographs persistent pain, swelling, weak toe push-off not recommended routinely findings will show disruption of volar plate Initial management of a Jones fracture includes a posterior splint and avoidance of weight-bearing activity, with follow-up in three to five days. Common presenting symptoms include bruising, swelling, and throbbing pain that worsens with a dependent position, although this type of pain also may occur with an isolated subungual hematoma. Fractures of the toes and forefoot are quite common. There is evidence that transitioning to a walking boot and then to a rigid-sole shoe (Figure 6) at four to six weeks, with progressive weight bearing as tolerated, results in improved functional outcomes compared with cast immobilization, with no differences in healing time or pain scores.12, Follow-up visits should occur every two to four weeks, with repeat radiography at four to six weeks to document healing.3,6 At six weeks, callus formation on radiography and lack of point tenderness generally signify adequate healing, after which immobilization can be discontinued.2,3,6. A fracture that is not treated can lead to chronic foot pain and arthritis and affect your ability to walk. While many Phalangeal fractures can be treated non-operatively, some do require surgery. (OBQ12.89) The thumb connects to the hand through the next joint, known as the metacarpophalangeal (MCP) joint. During this time, it may be helpful to wear a wider than normal shoe. Indications for referral of patients with first metatarsal fractures are different because the first metatarsal has a vital role in weight bearing and arch support. The image shows a diagram of where these bones lie in the footthe midpoint of the proximal phalanges being where to the toes branch off from the main body of the foot. During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. 21(1): p. 31-4. J Pediatr Orthop, 2001. Patients should be instructed to apply ice, elevate the foot above heart level, and use analgesics as needed. 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. Fractures can also develop after repetitive activity, rather than a single injury. RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. The proximal phalanx is the toe bone that is closest to the metatarsals. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. Epidemiology Incidence ORTHO BULLETS Orthopaedic Surgeons & Providers Percutaneous Reduction and Fixation of Displaced Phalangeal Neck Fractures in Children Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. A collegiate soccer player presents as a referral to your office after sustaining an injury to the right foot, which he describes as hyperdorsiflexion of the toes. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. Therefore, phalanges and digits adjacent to the fracture must be examined carefully; joint surfaces also must be examined for intra-articular fractures (Figure 3). Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. Copyright 2023 American Academy of Family Physicians. Joint hyperextension, a less common mechanism, may cause spiral or avulsion fractures. 68(12): p. 2413-8. (OBQ09.156) The most common symptoms of a fracture are pain and swelling. It is one of the most common fractures of the foot and has unique characteristics that make it more likely to require surgery. Follow-up radiographs may be taken three to six weeks after the injury, but they generally do not influence treatment and probably are not necessary in nondisplaced toe fractures. Toe and forefoot fractures often result from trauma or direct injury to the bone. Most commonly, the fifth metatarsal fractures through the base of the bone. Returning to activities too soon can put you at risk for re-injury. Kay, R.M. . All the bones in the forefoot are designed to work together when you walk. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. A, Dorsal PIPJ fracture-dislocation. Radiographic studies of a toe should include anteroposterior, lateral, and oblique views (Figure 1). Fractures of multiple phalanges are common (Figure 3). Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. A fracture, or break, in any of these bones can be painful and impact how your foot functions. Evidence has shown that, depending on symptoms, short leg walking boots are superior to short leg walking casts.18,19 Immobilization in a cast or boot is typically only needed for two weeks, with progressive ambulation and range of motion thereafter as tolerated. As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. 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. Mounts, J., et al., Most frequently missed fractures in the emergency department. The skin should be inspected for open wounds or significant injury that may lead to skin necrosis. This usually occurs from an injury where the foot and ankle are twisted downward and inward. Magnetic Resonance Imaging (MRI) scans. All rights reserved. A radiograph, bone scan, and MRI are found in Figures A-C, respectively. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. To enhance comfort, some patients prefer to cut out the part of the shoe that overlies the fractured toe. See permissionsforcopyrightquestions and/or permission requests. 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). Metatarsal shaft fractures near the head or base of the first to fourth metatarsal with any degree of displacement or angulation are often associated with concomitant injuries and generally take longer to heal. Tang, Pediatric foot fractures: evaluation and treatment. Sesamoid bones generally are present within flexor tendons in the first toe (Figure 1, top) and are found less commonly in the flexor tendons of other toes. Patient examination; . Copyright 2003 by the American Academy of Family Physicians. Clin OrthopRelat Res, 2005(432): p. 107-15. Pain is worsened with passive toe extension. If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. Hatch, R.L. 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. This procedure is most often done in the doctor's office. 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. 50(3): p. 183-6. Fractures can affect: Causes of lesser toe (phalangeal) fractures Trauma (generally something heavy landing on the toe or kicking an immovable object) Treatment of lesser toe (phalangeal) fractures Non-displaced fractures In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). 5th metatarsal most commonly fractured in adults, 1st metatarsal most commonly fractured in children less than 4 years old, 3rd metatarsal fractures rarely occur in isolation, 68% associated with fracture of 2nd or 4th metatarsal, peak incidence between 2nd and 5th decade of life, may have significant associated soft tissue injury, occurs with forefoot fixed and hindfoot or leg rotating, Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures, consider metabolic evaluation for fragility fracture, shape and function similar to metacarpals of the hand, first metatarsal has plantar crista that articulates with sesamoids, muscular balance between extrinsic and intrinsic muscles, Metatarsals have dense proximal and distal ligamentous attachments, 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with isolated fractures, implicated in formation of interdigital (Morton's) neuromas, multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to increased displacement, Classification of metatarsal fractures is descriptive and should include, look for antecedent pain when suspicious for stress fracture, foot alignment (neutral, cavovarus, planovalgus), focal areas or diffuse areas of tenderness, careful soft tissue evaluation with crush or high-energy injuries, evaluate for overlapping or malrotation with motion, semmes weinstein monofilament testing if suspicious for peripheral neuropathy, AP, lateral and oblique views of the foot, may be of use in periarticular injuries or to rule out Lisfranc injury, useful in detection of occult or stress fractures, second through fourth (central) metatarsals, non-displaced or minimally displaced fractures, evaluate for cavovarus foot with recurrent stress fractures, sagittal plane deformity more than 10 degrees, restore alignment to allow for normal force transmission across metatarsal heads, lag screws or mini fragment plates in length unstable fracture patterns, maintain proper length to minimize risk of transfer metatarsalgia, limited information available in literature, may lead to transfer metatarsalgia or plantar keratosis, treat with osteotomy to correct deformity, Majority of isolated metatarsal fractures heal with conservative management, Malunion may lead to transfer metatarsalgia, Posterior Tibial Tendon Insufficiency (PTTI).