9.29 Broken Toe
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agk's Library of Common Simple Emergencies

Presentation
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The patient has stubbed, hyperflexed, hyper- 
extended, 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
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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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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
 Longwood Information LLC 4822 Quebec St NW Wash DC
 1.202.237.0971 fax 1.202.244.8393 electra@clark.net
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