9.29 Broken Toe

agk’s Library of Common Simple Emergencies

Presentation

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.

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