High Yield Overview

PHALANGEAL FRACTURES FOOT

Great Toe | Lesser Toes | Usually Conservative

CommonMost common foot fracture

Great toeHallux most important

UsuallyConservative treatment

RarelyRequires ORIF

FRACTURE PATTERNS

Great toe

PatternHallux, most important

TreatmentConservative or ORIF

Lesser toes

Pattern2nd-5th toes, usually conservative

TreatmentConservative

Intra-articular

PatternJoint involvement

TreatmentORIF if displaced

Critical Must-Knows

Phalangeal fractures foot = most common foot fractures - great toe (hallux) most important, lesser toes usually conservative
Great toe requires better alignment - Hallux is critical for push-off, displacement greater than 2mm or intra-articular step-off requires ORIF
Lesser toes usually conservative - Buddy taping and early weight bearing usually sufficient, ORIF rarely needed
Intra-articular fractures - Displacement greater than 2mm or step-off requires ORIF to prevent arthritis
Usually conservative treatment - Most heal with buddy taping and protected weight bearing

Examiner's Pearls

"
Great toe most important - requires better alignment
"
Lesser toes usually conservative - buddy taping
"
Intra-articular displacement requires ORIF
"
Usually conservative treatment

Critical Phalangeal Fracture Foot Exam Points

Great Toe Critical

Great toe (hallux) most important - Critical for push-off and gait. Displacement greater than 2mm or intra-articular step-off requires ORIF. Lesser toes usually conservative with buddy taping.

Usually Conservative

Most phalangeal fractures heal with conservative treatment - Buddy taping and protected weight bearing. ORIF rarely needed - only for great toe displacement, intra-articular step-off, or open fractures.

Intra-Articular

Intra-articular fractures require ORIF if displaced - Step-off greater than 2mm causes arthritis. Great toe IP joint most critical. Screw or K-wire fixation.

Lesser Toes

Lesser toes (2nd-5th) usually conservative - Buddy taping and early weight bearing usually sufficient. ORIF rarely needed - only for severe displacement or open fractures.

Phalangeal Fractures Foot - Quick Decision Guide

Location	Displacement	Treatment	Outcome
Great toe	Less than 2mm, extra-articular	Conservative (buddy taping)	85-90% good results
Great toe	Greater than 2mm or intra-articular	ORIF	80-85% good results
Lesser toes	Any displacement	Conservative (buddy taping)	85-90% good results

Mnemonic

TOEPhalangeal Fracture Foot Features

Toe

Phalangeal fractures

Often

Usually conservative

Except

Great toe displacement

Memory Hook:TOE: Toe fractures, Often conservative, Except great toe displacement!

Mnemonic

GREATTreatment Decision

Great

Great toe critical

Requires

Better alignment

Extra

Extra care needed

Articular

Intra-articular ORIF

Treatment

ORIF if displaced

Memory Hook:GREAT: Great toe critical, Requires better alignment, Extra care needed, Articular fractures ORIF, Treatment ORIF if displaced!

Mnemonic

BUDDYLesser Toes

Buddy

Buddy taping

Usually

Usually sufficient

Displacement

Tolerates displacement

Displacement

Less critical

Yes

Yes, conservative

Memory Hook:BUDDY: Buddy taping, Usually sufficient, Displacement tolerated, Displacement less critical, Yes conservative!

Overview and Epidemiology

Phalangeal fractures of the foot are the most common foot fractures. Great toe (hallux) fractures require better alignment due to their importance in push-off, while lesser toe fractures are usually treated conservatively.

Definition

Phalangeal fracture foot: Fracture of the phalanges of the foot, which:

Location: Great toe (hallux) or lesser toes (2nd-5th)
Pattern: Proximal, middle, or distal phalanx
Treatment: Usually conservative, ORIF for great toe displacement
Outcome: Good with proper treatment

Great toe (hallux):

Most important: Critical for push-off and gait
Requires better alignment: Displacement greater than 2mm or intra-articular step-off requires ORIF
IP joint: Most critical joint

Lesser toes (2nd-5th):

Usually conservative: Buddy taping and protected weight bearing
Tolerates displacement: Less critical than great toe
ORIF rarely needed: Only for severe displacement or open fractures

Epidemiology

Incidence: Most common foot fractures
Age: All ages, peak 20-40 years
Gender: No clear predominance
Mechanism: Crush injury, stubbing, direct trauma
Associated injuries: Other foot injuries, open fractures

Great Toe Critical

Great toe (hallux) most important - Critical for push-off and gait. Displacement greater than 2mm or intra-articular step-off requires ORIF. Lesser toes usually conservative with buddy taping.

Anatomy and Pathophysiology

Phalangeal Anatomy

Great toe (hallux):

Proximal phalanx: Largest, articulates with 1st metatarsal
Distal phalanx: Smaller, tuft fractures common
IP joint: Interphalangeal joint, critical for push-off
Function: Critical for gait and push-off

Lesser toes (2nd-5th):

Proximal phalanx: Articulates with metatarsal
Middle phalanx: 2nd-4th toes (3rd toe may have only 2 phalanges)
Distal phalanx: Tuft fractures common
Function: Less critical than great toe

Deforming forces:

Great toe: Flexor and extensor tendons
Lesser toes: Similar but less significant
Intrinsic muscles: Minimal deforming force

Pathophysiology

Injury mechanism:

Crush injury: Most common (stubbing, dropping object)
Direct trauma: To toe
Axial loading: During push-off

Why great toe requires better alignment:

Push-off function: Critical for gait
IP joint: Most important joint
Arthritis risk: Malunion causes arthritis

Why lesser toes usually conservative:

Less critical function: Tolerates displacement
Compensatory motion: Adjacent toes compensate
Good healing: Most heal with conservative treatment

Classification Systems

Location-Based Classification

Great toe (hallux):

Proximal phalanx
Distal phalanx
IP joint
Treatment: Conservative or ORIF

Lesser toes (2nd-5th):

Proximal phalanx
Middle phalanx (2nd-4th)
Distal phalanx
Treatment: Usually conservative

Location guides treatment approach.

Clinical Assessment

History

Symptoms:

Toe pain: Pain in affected toe
Swelling: Localised to toe
Difficulty weight bearing: Pain with weight bearing
Mechanism: Crush injury, stubbing, direct trauma

Risk factors:

Crush injuries
Stubbing toes
Direct trauma

Physical Examination

Inspection:

Swelling in toe
Ecchymosis (may be delayed)
Deformity (angulation, rotation)

Palpation:

Tenderness over fracture site
Crepitus (if unstable)
Deformity (if displaced)

Range of Motion:

Toe ROM limited and painful
IP joint ROM (great toe)

Special tests:

Alignment check: Check for angulation and rotation
IP joint stability: Test great toe IP joint
Weight bearing: Pain with weight bearing

Clinical Examination Key Point

Check alignment carefully - Great toe requires better alignment (displacement greater than 2mm or intra-articular step-off requires ORIF). Lesser toes usually tolerate displacement. Check for angulation and rotation.

Investigations

Standard X-ray Protocol

AP view:

Shows fracture pattern
Assess displacement
Check alignment

Lateral view:

Shows angulation
Assess IP joint (great toe)

Oblique view:

May show fracture better
Less commonly needed

Key point: X-rays usually sufficient for diagnosis.

Management Algorithm

Management Pathway

Phalangeal Fracture Foot Management

DiagnosisX-rays Usually Sufficient

X-rays usually sufficient for diagnosis - AP and lateral views show fracture pattern and displacement. Assess alignment, articular involvement, and displacement.

Great ToeAlignment Critical

Great toe requires better alignment - Displacement greater than 2mm or intra-articular step-off requires ORIF. Conservative treatment for non-displaced or minimally displaced. Success rate 80-85% with ORIF.

Lesser ToesUsually Conservative

Lesser toes usually conservative - Buddy taping and protected weight bearing usually sufficient. ORIF rarely needed - only for severe displacement or open fractures. Success rate 85-90% with conservative treatment.

Intra-ArticularORIF if Displaced

Intra-articular fractures require ORIF if step-off greater than 2mm - Prevents arthritis. Great toe IP joint most critical. Screw or K-wire fixation. Success rate 80-85%.

Surgical Technique

ORIF Great Toe Technique

Indications:

Displacement greater than 2mm
Intra-articular step-off greater than 2mm
Unstable fracture pattern

Approach:

Medial or dorsal approach
Expose fracture
Protect neurovascular structures

Technique:

Exposure: Medial or dorsal approach to great toe, expose fracture, protect neurovascular structures
Reduction: Anatomic reduction of fracture, restore IP joint congruity if intra-articular
Fixation: Screws (1.5-2.0mm) or K-wires (1.0-1.5mm)
Verification: Confirm reduction and hardware position fluoroscopically

Advantages:

Restores alignment
Prevents arthritis
Allows early motion

ORIF for great toe displacement.

Complications

Complication	Incidence	Risk Factors	Prevention/Management
Malunion	5-10%	Displacement, inadequate reduction	Anatomic reduction, ORIF if needed
Arthritis	10-15%	Intra-articular malunion	Anatomic reduction, ORIF if step-off
Stiffness	10-15%	Prolonged immobilization	Early motion, buddy taping
Nonunion	2-5%	Displacement, inadequate fixation	Rigid fixation

Malunion

5-10% incidence:

Cause: Displacement, inadequate reduction
Prevention: Anatomic reduction, ORIF if needed
Management: Corrective osteotomy if symptomatic

Arthritis

10-15% incidence (if intra-articular malunion):

Cause: Intra-articular step-off, malunion
Prevention: Anatomic reduction, ORIF if step-off greater than 2mm
Management: IP joint fusion if severe

Postoperative Care

Immediate Postoperative

Immobilisation: Buddy taping or splint
Weight bearing: Protected weight bearing
ROM: Toe ROM exercises early
PT: Not usually needed

Rehabilitation Protocol

Weeks 0-3:

Buddy taping or splint
Protected weight bearing
Toe ROM exercises

Weeks 3-4:

Remove K-wires if used
Progressive weight bearing
Full activity

Weeks 4-6:

Full weight bearing
Return to sport (6-8 weeks)

Outcomes and Prognosis

Overall Outcomes

Conservative treatment:

Success rate: 85-90% (union, pain relief)
Functional outcomes: 80-85% return to pre-injury level
Great toe: 80-85% good results

ORIF (great toe):

Success rate: 80-85% (union, pain relief)
Functional outcomes: 75-80% return to pre-injury level
Arthritis: 10-15% develop IP joint arthritis

Conservative (lesser toes):

Success rate: 85-90% (union, pain relief)
Functional outcomes: 85-90% return to pre-injury level
Complications: Rare

Long-Term Prognosis

Arthritis progression:

With proper treatment: 10-15% develop IP joint arthritis (great toe)
Without treatment: 20-30% develop arthritis
Risk factors: Intra-articular malunion, displacement

Evidence Base

Phalangeal Fractures Foot

Case Series

Shereff et al • Foot Ankle Int, 2001 (2001)

Key Findings:

Most common foot fractures
Great toe requires better alignment (80-85% good results with ORIF)
Lesser toes usually conservative (85-90% good results)
Usually conservative treatment

Clinical Implication: Prioritize conservative management for most lesser toe fractures

Great Toe Fractures

Case Series

Shereff et al • Foot Ankle Int, 2001 (2001)

Key Findings:

Great toe most important
Displacement greater than 2mm requires ORIF (80-85% good results)
Intra-articular step-off requires ORIF
IP joint most critical

Clinical Implication: Restore articular congruity to prevent hallux rigidus

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Great Toe Displaced Fracture

EXAMINER

"A 30-year-old patient presents with great toe pain after stubbing injury. X-rays show displaced proximal phalanx fracture of great toe with 3mm displacement and 5 degrees angulation."

EXCEPTIONAL ANSWER

This is a displaced great toe (hallux) proximal phalanx fracture in a 30-year-old patient. I would take a systematic approach: First, confirm the diagnosis: Displaced great toe proximal phalanx fracture with 3mm displacement (greater than 2mm threshold) and 5 degrees angulation, great toe pain after stubbing injury. The great toe is critical for push-off and gait, and requires better alignment than lesser toes. Second, assess severity: 3mm displacement exceeds the 2mm threshold for surgical treatment. Angulation of 5 degrees may be acceptable depending on location, but displacement requires ORIF. Third, surgical management: ORIF is required for displaced great toe fractures to restore alignment and prevent malunion. Technique: Medial or dorsal approach to great toe, expose fracture, protect neurovascular structures, reduce fracture anatomically, restore alignment, fix with screws (1.5-2.0mm) or K-wires (1.0-1.5mm), verify reduction and hardware position fluoroscopically. Postoperatively, I would use buddy taping or splint with protected weight bearing for 3-4 weeks, then progressive weight bearing, and monitor with serial X-rays. I would counsel about good outcomes (80-85% good results with ORIF) but potential complications (malunion 5-10%, arthritis 10-15% if intra-articular malunion). The key point is that great toe displacement greater than 2mm requires ORIF to restore alignment and prevent malunion, as the great toe is critical for push-off and gait.

KEY POINTS TO SCORE

Great toe most important - requires better alignment

Displacement greater than 2mm requires ORIF

Restore alignment to prevent malunion

ORIF required (80-85% good results)

COMMON TRAPS

✗Treating like lesser toe - great toe requires better alignment

✗Not using ORIF for displacement - causes malunion

✗Missing the diagnosis - X-rays usually sufficient

✗Not understanding great toe importance

LIKELY FOLLOW-UPS

"Why is great toe more important than lesser toes?"

"When would you use conservative treatment for great toe?"

"What are the complications of untreated fractures?"

VIVA SCENARIOStandard

Scenario 2: Lesser Toe Fracture

EXAMINER

"A 25-year-old patient presents with 3rd toe pain after crush injury. X-rays show displaced middle phalanx fracture with 4mm displacement and 10 degrees angulation."

EXCEPTIONAL ANSWER

This is a displaced 3rd toe middle phalanx fracture in a 25-year-old patient. I would take a systematic approach: First, confirm the diagnosis: Displaced 3rd toe middle phalanx fracture with 4mm displacement and 10 degrees angulation, 3rd toe pain after crush injury. Lesser toes (2nd-5th) are less critical than great toe and usually tolerate displacement. Second, assess severity: 4mm displacement and 10 degrees angulation are significant, but lesser toes usually tolerate this better than great toe. No intra-articular involvement. Third, management: Conservative treatment is usually sufficient for lesser toe fractures, even with displacement. Protocol: Buddy taping to adjacent toe (2nd or 4th), protected weight bearing, duration 3-4 weeks, serial X-rays to monitor healing, progressive weight bearing after healing. I would counsel about excellent outcomes (85-90% good results with conservative treatment) and that ORIF is rarely needed for lesser toes - only for severe displacement, open fractures, or failed conservative treatment. The key point is that lesser toes usually tolerate displacement and are treated conservatively with buddy taping, as they are less critical than great toe for push-off and gait.

KEY POINTS TO SCORE

Lesser toes usually conservative

Tolerate displacement better than great toe

Buddy taping usually sufficient

ORIF rarely needed (85-90% good results with conservative)

COMMON TRAPS

✗Over-treating with ORIF - lesser toes usually conservative

✗Not using buddy taping - standard treatment

✗Treating like great toe - lesser toes tolerate displacement

✗Not understanding lesser toe tolerance

LIKELY FOLLOW-UPS

"When would you use ORIF for lesser toes?"

"Why do lesser toes tolerate displacement better?"

"What is the buddy taping technique?"

MCQ Practice Points

Great Toe

Q: Why does the great toe require better alignment than lesser toes? A: Great toe is critical for push-off and gait - Displacement greater than 2mm or intra-articular step-off requires ORIF. IP joint most critical. Success rate 80-85% with ORIF.

Lesser Toes

Q: How are lesser toe fractures treated? A: Usually conservative with buddy taping - Lesser toes tolerate displacement better than great toe. Buddy taping and protected weight bearing usually sufficient. ORIF rarely needed. Success rate 85-90% with conservative treatment.

Intra-Articular

Q: When is ORIF required for phalangeal fractures of the foot? A: Great toe displacement greater than 2mm or intra-articular step-off greater than 2mm - Prevents malunion and arthritis. Lesser toes rarely need ORIF - only for severe displacement or open fractures.

Treatment

Q: What is the treatment for phalangeal fractures of the foot? A: Usually conservative with buddy taping - Most heal with buddy taping and protected weight bearing. ORIF for great toe displacement (greater than 2mm) or intra-articular step-off. Success rate 85-90% with conservative, 80-85% with ORIF.

Complications

Q: What are the complications of phalangeal fractures of the foot? A: Malunion (5-10%), arthritis (10-15% if intra-articular malunion), stiffness (10-15%) - Prevent with anatomic reduction and ORIF if needed. Early motion prevents stiffness. Success rate 85-90% with proper treatment.

Australian Context

Clinical Practice

Phalangeal fractures most common foot fractures
Great toe requires better alignment
Lesser toes usually conservative
ORIF rarely needed

Healthcare System

Public hospitals handle most cases
Private insurance covers procedures
Common injuries

Orthopaedic Exam Relevance

Phalangeal fractures of the foot are a common viva topic. Know that great toe most important (requires better alignment, displacement greater than 2mm requires ORIF), lesser toes usually conservative (buddy taping, 85-90% good results), intra-articular step-off requires ORIF (prevents arthritis), and usually conservative treatment. Be prepared to discuss the difference between great toe and lesser toe treatment.