Foot Fractures - Phalanx

Key Points:

  • One of the most common foot fractures in children
  • Often not treated by orthopedic surgeons
  • Open fractures require irrigation & debridement
  • Nail-bed injuries involving the germinal matrix should be repaired
  • Displaced intra-articular fractures of the hallux require reduction

Description:

Fractures of the phalanx are the most common type of foot fractures in the pediatric population. The vast majority of pediatric foot fractures do well with non-operative management.(Kay 2001)  Surgical treatment is recommended for open fractures, significantly displaced fractures, and displaced intra-articular fractures of the hallux.

Epidemiology:

Pediatric phalanx fractures are one of the most common fractures in children.  Fractures of the foot account for approximately 5% to 13% of all pediatric fractures.  Fractures of the toes represent the most common foot fractures in the pediatric age group and may account for as many as 18% of pediatric foot fractures.  Phalangeal fractures represent 3% to 7% of all physeal fractures and are usually Salter-Harris type I or type II injuries.(Kay 2001) Pediatric phalanx fractures are more common in boys than girls and are most commonly closed injuries.

Clinical Findings:

Pediatric patients with phalanx fractures have a broad presentation.  They can present with localized pain to the affected toe, a limp or with the inability to weight bear.  It is important for the examining physician to obtain a detailed history and physical exam, which can be often difficult in the young, non-cooperative, injured child.(Hatch 2003)  Evaluation of the point of maximal tenderness and close evaluation of the integrity of the skin around the toe should be performed to ensure that there is not a nail-bed injury.  Signs such as nail-bed bleeding and bleeding from or around the nail fold should alert the treating physician to the presence of an open fracture through the nail bed.(Kensinger 2001)  Alignment, rotation and neurovascular status should also be evaluated.(Kay 2001)

Etiology:

Phalangeal fractures usually result from objects falling onto the foot or stubbing a toe.(Ribbans 2005)  Injuries to the hallux have been found to commonly occur during sporting activities (28%), especially soccer, with most patients (92%) presenting with closed fractures.(Petnehazy 2015)  Serious foot and toe injuries can also occur from high energy trauma, including all-terrain vehicle (ATV) accidents and lawnmower injuries which can result in complex fractures, degloving injuries and traumatic amputations.(Thompson 2008, Vollman 2006)

Treatment:

Fractures of the foot in children usually have a good prognosis and most are treated non-operatively.(Ribbans 2005)Closed fractures rarely require reduction. Fractures of the second to fifth toes are typically treated with buddy taping and are allowed to be weight bearing as tolerated.(Hatch 2003)  These fractures heal almost universally without mal-alignment within 3 to 4 weeks.(Petnehazy 2015)  A hard-soled shoe or short leg walking cast may be used for patient comfort until fracture healing has occurred

Open fractures of the foot phalanges require thorough irrigation and débridement in addition to antibiotics to avoid osteomyelitis.  A nail-bed injury to the germinal matrix may require surgical repair.(Kay 2001, Kensinger 2001)

Fractures of the proximal phalanx of the hallux involving the epiphysis may be intra-articular. If more than 25% of the joint surface is involved or if the displacement is more than 2 to 3 mm, closed or open reduction is indicated. Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment.(Kay 2001)

Complications:

The vast majority of pediatric phalanx fractures heal without any clinical or radiographic complications.  The most common complications include growth-arrest and angular deformities from physeal injury, degenerative joint disease from intra-articular fractures and osteomyelitis from open fractures.  Other uncommon sequelae of phalangeal fractures include stiffness and pain.(Kay 2001, Petnehazy 2015, Hatch 2003, Maffulli 2001) 

References:

  1. Hatch, R.L. and S. Hacking, Evaluation and management of toe fractures. Am Fam Physician, 2003. 68(12): p. 2413-8.
  2. Kay, R.M. and C.W. Tang, Pediatric foot fractures: evaluation and treatment. J AmAcad Orthop Surg, 2001. 9(5): p. 308-19.
  3. Kensinger, D.R., et al., The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx. J Pediatr Orthop, 2001. 21(1): p. 31-4.
  4. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. Clin J Sport Med, 2001. 11(2): p. 121-3.
  5. Mounts, J., et al., Most frequently missed fractures in the emergency department. ClinPediatr (Phila), 2011. 50(3): p. 183-6.
  6. Petnehazy, T., et al., Fractures of the hallux in children. Foot Ankle Int, 2015. 36(1)p. 60-3.
  7. Ribbans, W.J., R. Natarajan, and S. Alavala, Pediatric foot fractures. Clin OrthopRelat Res, 2005(432): p. 107-15.
  8. Thompson, T.M., et al., Foot injuries associated with all-terrain vehicle use in children and adolescents. Pediatr Emerg Care, 2008. 24(7): p. 466-7.
  9. Vollman, D. and G.A. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. Pediatrics, 2006. 118(2): p. e273-8.

Top Contributors:

Kevin Smit MD