The patient has stubbed, hyperflexed, hyperextended,
hyperabducted, or dropped a weight upon a toe. He presents
with pain swelling, ecchymosis, decreased range of motion
and point tendeness, and there may or may not be any
deformity.
What to do:
Examine the toe, particularly for lacerations which could
become infected, prolanged capillary filling time in the
injured or other toes which could indicate poor circulation,
or decreased sensation in the injured or other toes which
could indicate peripheral neuropathy, and may interfere with
healing.
X rays are not essential but are often necessary to provide
patient satisfaction. They have little effect on the initial
treatment, but may help predict the duration of pain and
disability (e.g., fractures entering the joint space).
Displaced or angulated phalangeal fractures must be reduced
with linear traction after a digital block. Angulation can
be further corrected by using your finger as a fulcrum to
reverse the direction of the distal fragment. The broken toe
should fall into its normal position when it is released
after reduction.
Splint the broken toe by taping it to an adjacent non-
affected toe, padding between toes with gauze or Webril, and
using half-inch tape. Give the patient additional padding
and tape, so he may revise the splinting, and (if there is a
fracture) advise him that he will require such
immobilization for approximately one week, by which time
there should be good callus formation around the fracture
and less pain with motion. Inform the patient that he must
keep the padding dry between his toes while they are taped
together or the skin will become mace rated and will break
down.
Also treat with rest, ice, elevation, and anti-inflammatory
medication. A cane, crutches, or hard-soled shoes which
minimize toe flexion may all provide comfort. Let the
patient know that in many cases a soft slipper or an old
sneaker with the toe cut out may be more comfortable.
If the fracture is not of a phalanx, but of the metatarsal,
buddy taping is not effective. Instead, construct a pad for
the sole with space cut out under the fracture site and the
distal metatarsal head, either taped to the foot, or,
ideally inside a roomy cast shoe used for walking casts.
Arrange for followup if the toe is not much better within
one week.
What not to do:
Do not tape toes together without padding between them.
Friction and wetness will macerate the skin between.
Do not let the patient overdo ice, which should not be
applied directly to skin, and should not be used for more
than 10-20 minutes per hour.
Do not overlook the possibility of acute gouty arthritis,
which sometimes follows minor trauma after a delay of a few
hours.
Discussion
If there is no toe fracture, the treatment is the same, but
the pain, swelling, and ability to walk may improve in 3
days rather than 1-2 weeks. Although patients still come to
the ED asking whether the toe is broken, they can usually be
handled adequately over the telephone and seen the next day.
