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Emergency And Acute Medicine – Phalangeal Injuries, Foot
Phalangeal injuries of the foot are common, with the fifth (small) toe most frequently affected. These injuries usually result from direct trauma such as stubbing the toe, kicking a hard object, or dropping a heavy item onto the foot. Although many are minor, certain patterns—particularly those involving the great toe (hallux), intra-articular surfaces, or open wounds—require careful evaluation and possible orthopedic consultation.
Patients typically present with localized pain, swelling, bruising, and difficulty bearing weight. The history should include the time and mechanism of injury, prior trauma to the digit, and tetanus immunization status if a laceration is present. On examination, findings may include tenderness, swelling, crepitus, ecchymosis, and occasionally subungual hematoma. Lacerations or crush injuries may also be present. Neurovascular status of the affected digit must always be documented. Radiographs of the involved digit are essential for diagnosis, and the lateral view is often the most sensitive for detecting fractures or dislocations.
Fractures of the proximal phalanx or interphalangeal (IP) joint of the hallux require particular attention. Nondisplaced, non–intra-articular fractures can be treated with a short-leg walking cast with toe extension for comfort. Displaced fractures may require closed reduction under digital block anesthesia with longitudinal traction, followed by immobilization. Intra-articular fractures of the hallux warrant orthopedic consultation and are often managed with open reduction and internal fixation. Fractures involving the lesser toes rarely cause long-term disability. Nondisplaced fractures are typically treated with buddy taping and gauze padding between toes to prevent skin breakdown. Displaced fractures may be reduced under digital block anesthesia, followed by buddy taping or splinting and use of a hard-sole shoe with weight bearing as tolerated. Pain usually resolves within 2–3 weeks.
Interphalangeal joint dislocations are managed with closed reduction using digital block anesthesia and longitudinal traction with gentle pressure on the distal phalanx, followed by buddy taping. Unstable or irreducible dislocations require orthopedic consultation. Distal tuft fractures are commonly associated with subungual hematomas, which should be drained. Nail-bed lacerations may require repair. Buddy taping and weight bearing as tolerated are generally sufficient, with pain resolving in 2–3 weeks. Open fractures require urgent orthopedic consultation and prophylactic antibiotics.
Pain control is typically achieved with NSAIDs such as ibuprofen, though narcotic analgesics may be necessary for severe pain. Open fractures may require intravenous cefazolin in the emergency department and oral cephalexin for contaminated wounds. Admission is indicated for unstable or irreducible dislocations and open fractures requiring immediate orthopedic management. Most other fractures can be discharged with orthopedic follow-up in 2–3 weeks. Intra-articular fractures of the great toe require urgent specialist follow-up, while simple nondisplaced fractures of the lesser toes may be managed by primary care providers. Open, displaced, or intra-articular fractures—particularly those involving the hallux—should prompt early orthopedic consultation to reduce the risk of long-term functional impairment.
Phalangeal injuries of the foot are common, with the fifth (small) toe most frequently affected. These injuries usually result from direct trauma such as stubbing the toe, kicking a hard object, or dropping a heavy item onto the foot. Although many are minor, certain patterns—particularly those involving the great toe (hallux), intra-articular surfaces, or open wounds—require careful evaluation and possible orthopedic consultation.
Patients typically present with localized pain, swelling, bruising, and difficulty bearing weight. The history should include the time and mechanism of injury, prior trauma to the digit, and tetanus immunization status if a laceration is present. On examination, findings may include tenderness, swelling, crepitus, ecchymosis, and occasionally subungual hematoma. Lacerations or crush injuries may also be present. Neurovascular status of the affected digit must always be documented. Radiographs of the involved digit are essential for diagnosis, and the lateral view is often the most sensitive for detecting fractures or dislocations.
Fractures of the proximal phalanx or interphalangeal (IP) joint of the hallux require particular attention. Nondisplaced, non–intra-articular fractures can be treated with a short-leg walking cast with toe extension for comfort. Displaced fractures may require closed reduction under digital block anesthesia with longitudinal traction, followed by immobilization. Intra-articular fractures of the hallux warrant orthopedic consultation and are often managed with open reduction and internal fixation. Fractures involving the lesser toes rarely cause long-term disability. Nondisplaced fractures are typically treated with buddy taping and gauze padding between toes to prevent skin breakdown. Displaced fractures may be reduced under digital block anesthesia, followed by buddy taping or splinting and use of a hard-sole shoe with weight bearing as tolerated. Pain usually resolves within 2–3 weeks.
Interphalangeal joint dislocations are managed with closed reduction using digital block anesthesia and longitudinal traction with gentle pressure on the distal phalanx, followed by buddy taping. Unstable or irreducible dislocations require orthopedic consultation. Distal tuft fractures are commonly associated with subungual hematomas, which should be drained. Nail-bed lacerations may require repair. Buddy taping and weight bearing as tolerated are generally sufficient, with pain resolving in 2–3 weeks. Open fractures require urgent orthopedic consultation and prophylactic antibiotics.
Pain control is typically achieved with NSAIDs such as ibuprofen, though narcotic analgesics may be necessary for severe pain. Open fractures may require intravenous cefazolin in the emergency department and oral cephalexin for contaminated wounds. Admission is indicated for unstable or irreducible dislocations and open fractures requiring immediate orthopedic management. Most other fractures can be discharged with orthopedic follow-up in 2–3 weeks. Intra-articular fractures of the great toe require urgent specialist follow-up, while simple nondisplaced fractures of the lesser toes may be managed by primary care providers. Open, displaced, or intra-articular fractures—particularly those involving the hallux—should prompt early orthopedic consultation to reduce the risk of long-term functional impairment.
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