An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. A 55 year-old woman comes to you with 2 months of right foot pain. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. Abductor, interosseus, and adductor muscles insert at the proximal aspects of each proximal phalanx. These include metatarsal fractures, which account for 35% of foot fractures.2,3 About 80% of metatarsal fractures are nondisplaced or minimally displaced, which often makes conservative management appropriate.4 In adults and children older than five years, fractures of the fifth metatarsal are most common, followed by fractures of the third metatarsal.5 Toe fractures, the most common of all foot fractures, will also be discussed. To enhance comfort, some patients prefer to cut out the part of the shoe that overlies the fractured toe. Healing time is typically four to six weeks. After the splint is discontinued, the patient should begin gentle range-of-motion (ROM) exercises with the goal of achieving the same ROM as the same toe on the opposite foot. If you need surgery it is best that this be performed within 2 weeks of your fracture. A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). Clin J Sport Med, 2001. Nondisplaced acute metatarsal shaft fractures generally heal well without complications. Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, He Is Playing With Nonoperative Treatment - Michael Coughlin, MD, He Is Out! The Ottawa Ankle and Foot Rules should be applied when examining patients with suspected fractures of the proximal fifth metatarsal to help decide whether radiography is needed14 (Figure 815 ). Radiographic studies of a toe should include anteroposterior, lateral, and oblique views (Figure 1). If the bone is out of place, your toe will appear deformed. 2017 Oct 01;:1558944717735947. About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an FAAOS Surgeon. The fractures reviewed in this article are summarized in Table 1. Open fractures, Infection, Compartment syndrome 3; References, Classification, Courses 3; Distal articular. A fifth metatarsal tuberosity avulsion fracture can be treated acutely with a compressive dressing, then the patient can be transitioned to a short leg walking boot for two weeks, with progressive mobility as tolerated after initial immobilization. The distal phalanx is the most common location for a non-physeal injury which typically involves a crushing mechanism, and the most common location for physeal injury is the proximal phalanx. Examination should consist of a neurovascular evaluation and palpation of the foot and ankle. Copyright 2023 American Academy of Family Physicians. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. Magnetic Resonance Imaging (MRI) scans. ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. Petnehazy, T., et al., Fractures of the hallux in children. An X-ray can usually be done in your doctor's office. Follow-up radiographs may be taken three to six weeks after the injury, but they generally do not influence treatment and probably are not necessary in nondisplaced toe fractures. 50(3): p. 183-6. The talus has a head, constricted neck, and body. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Shaft. Three muscles, viz. Surgery is not often required. Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured. As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. Thank you. Phalangeal fractures are the most common foot fracture in children. We help you diagnose your Hand Proximal phalanx case and provide detailed descriptions of how to manage this and hundreds of other pathologies. Proximal interphalangeal joint (PIPJ) dislocation is one of the most common hand injuries. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. Management is determined by the location of the fracture and its effect on balance and weight bearing. Bite The Bullet, He Needs Long Term Function: Be The Hated Person - Robert Anderson, MD. Most fifth metatarsal fractures can be treated with weight bearing as tolerated, and immobilization in a cast or walking boot. Recent studies have demonstrated that musculoskeletal ultrasonography and traditional radiography have comparable accuracy, sensitivity, and specificity in the diagnosis of foot and ankle fractures9,10 (Figure 1). Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. In one rural family practice,1 toe fractures comprised 8 percent of 295 fractures diagnosed; in an Air Force family practice residency program,2 they made up 9 percent of 624 fractures treated. Unlike an X-ray, there is no radiation with an MRI. Continue to learn and join meaningful clinical discussions . To minimize the possibility of future disability, the position of the bone fragments after reduction should be as close to anatomic as possible. Proximal hallux. Adjuvant imaging techniques to analyze fracture geometry and plan implant placement, will be discussed in detail. Nondisplaced fractures usually are less apparent; however, most patients with toe fractures have point tenderness over the fracture site. Some metatarsal fractures are stress fractures. Copyright 2023 Lineage Medical, Inc. All rights reserved. The flexor and extensor tendons impart a longitudinal compression force, which can shorten the phalanx and extend the distal fragment [ 1 ]. Patients have localized pain, swelling, and inability to bear weight on the lateral aspect of the foot. CrossRef Google Scholar PubMed 7 DeVries, JG, Taefi, E, Bussewitz, BW, Hyer, CF, Lee, TH. These bones comprise 2 bones in the hindfoot (calcaneus, talus), [ 1, 2] 5 bones in the midfoot (navicular, cuboid, 3. He states he has a 30-year-old lumberjack who earlier today was playing softball in the county championship when he slid into home plate in the bottom of the 9th inning. At the first follow-up visit, radiography should be performed to assure fracture stability. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. Common mechanisms of injury include: Axial loading (stubbing toe) Abduction injury, often involving the 5th digit Crush injury caused by a heavy object falling on the foot or motor vehicle tyre running over foot Less common mechanism: Follow-up/referral. Diagnosis is made with plain radiographs of the foot. Patients with these fractures should be referred to an orthopedist.2,3,6, The fifth metatarsal has the least cortical thickness of all the metatarsals.13 There are multiple strong ligamentous and capsular attachments surrounding the proximal fifth metatarsal; these allow stresses to be directed through this portion of the bone.13 Classically, fractures of the proximal fifth metatarsal can be classified based on anatomic location into one or more of three zones (Figure 7).3. They typically involve the medial base of the proximal phalanx and usually occur in athletes. most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). The preferred splinting technique is to buddy tape the affected toe to an adjacent toe (Figure 7).4 Treatment should continue until point tenderness is resolved, usually at least three weeks (four weeks for fractures of the first toe). Narcotic analgesics may be necessary in patients with first-toe fractures, multiple fractures, or fractures requiring reduction. and S. Hacking, Evaluation and management of toe fractures. During this time, it may be helpful to wear a wider than normal shoe. Foot radiography is required if there is pain in the midfoot zone and any of the following: bone tenderness at point C (base of the fifth metatarsal) or D (navicular), or inability to bear weight immediately after the injury and at the time of examination.14 When used properly, the Ottawa Ankle and Foot Rules have a sensitivity of 99% and specificity of 58%, with a positive likelihood ratio of 2.4 and a negative likelihood ratio of 0.02 for detecting fractures. Radiographs are shown in Figure A. 36(1)p. 60-3. Follow-up visits should be scheduled every two weeks, and healing time varies from four to eight weeks.3,6 Follow-up radiography is typically required only at six to eight weeks to document healing, or earlier if the patient has persistent localized pain or continued painful ambulation at four weeks.2,3,6. Diagnosis requires radiographic evaluation, although emerging evidence demonstrates that ultrasonography may be just as accurate. In most cases, a fracture will heal with rest and a change in activities. They most often involve the metatarsals and toes. Foot fractures are among the most common foot injuries evaluated by primary care physicians. A fractured toe may become swollen, tender, and discolored. Common presenting symptoms include bruising, swelling, and throbbing pain that worsens with a dependent position, although this type of pain also may occur with an isolated subungual hematoma. The patient notes worsening pain at the toe-off phase of gait. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. The proximal phalanx is the toe bone that is closest to the metatarsals. Your video is converting and might take a while Feel free to come back later to check on it. In P_STAR, 2 distraction pins are placed 1.5 cm proximal and distal to the fracture site in clearance of the distal radial physis. An attempt at reduction and immobilization is made in the field by his unit physician assistant, and he returns to your office one week later. Hallux fractures. A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. The nail should be inspected for subungual hematomas and other nail injuries. . Great toe fractures are generally treated with a short leg walking cast with a toe plate (Figure 1311 ) that extends past the great toe or with a short leg walking boot for two to three weeks.6 After this time, and in the absence of significant symptoms, the patient can progress to buddy taping and use of a rigid-sole shoe for three to four weeks.6,23,24 Range-of-motion exercises can generally be initiated at four weeks. Application of a gentle axial loading force distal to the injury (i.e., compressing the distal phalanx toward the foot) may distinguish contusions from fractures. He undergoes closed reduction and pinning shown in Figure B to correct alignment. Proximal phalanx fractures often present with apex volar angulation. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. If you have an open fracture, however, your doctor will perform surgery more urgently. A walking cast with a toe platform may be necessary in active children and in patients with potentially unstable fractures of the first toe. For acute metatarsal shaft fractures, indications for surgical referral include open fractures, fracture-dislocations, multiple metatarsal fractures, intra-articular fractures, and fractures of the second to fifth metatarsal shaft with at least 3 mm displacement or more than 10 angulation in the dorsoplantar plane. If the reduction is unstable (i.e., the position is not maintained after traction is released), splinting should not be used to hold the reduction, and referral is indicated. Deformity of the digit should be noted; most displaced fractures and dislocations present with visible deformity. Your foot may become swollen and discolored after a fracture. Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). This content is owned by the AAFP. An AP radiograph is shown in FIgure A. The middle phalanx (P2) is dislocated or subluxated dorsally, and the volar lip is fractured at its base. Surgery may be delayed for several days to allow the swelling in your foot to go down. The appropriate treatment depends on the location of the fracture, the amount of displacement (shifting of the two ends of the fracture), and activity level of the patient. Your doctor will tell you when it is safe to resume activities and return to sports. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. Lightly wrap your foot in a soft compressive dressing. Toe fracture (Redirected from Toe Fracture) Contents 1 Background 2 Clinical Features 3 Differential Diagnosis 3.1 Foot and Toe Fractures 3.1.1 Hindfoot 3.1.2 Midfoot 3.1.3 Forefoot 4 Management 4.1 General Fracture Management 4.2 Immobilization 5 Disposition 6 See Also 7 References Background Bones of the foot. Repeat radiography is indicated and should be obtained one week post-fracture if there was intra-articular involvement or if a reduction was required. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. And finally, the webinar will cover fixation techniques, including various instrumentation options.Moderator:Jeffrey Lawton, MDChief, Hand and Upper ExtremityProfessor, Orthopaedic SurgeryAssociate Chair for Quality and Safety, Orthopaedic SurgeryProfessor, Plastic SurgeryUniversity of MichiganAnn Arbor, MichiganFaculty: Charles Cassidy, MDHenry H. Banks Professor and ChairmanDepartment of OrthopaedicsTufts Medical CenterBoston, MassachusettsChaitanya Mudgal, MD, MS (Ortho), MChHand Surgery ServiceDepartment of OrthopedicsMassachusetts General HospitalChairman, AO NA Hand Education CommitteeAssociate Professor, Orthopedic Surgery, Harvard Medical SchoolBoston, MassachusettsAmit Gupta, MD, FRCSProfessorDepartment of Orthopaedic SurgeryUniversity of LouisvilleLouisville, KentuckyRebecca Neiduski, PhD, OTR/L, CHTDean of the School of Health SciencesProfessor of Health SciencesElon UniversityElon, North Carolina, Ring Finger Proximal Phalanx Fracture in 16M. Copyright 2003 by the American Academy of Family Physicians. 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. In many cases, anteroposterior and oblique views are the most easily interpreted (Figure 1, top and bottom). Referral is recommended for patients with first-toe fracture-dislocations, displaced intra-articular fractures, and unstable displaced fractures (i.e., fractures that spontaneously displace when traction is released following reduction). Started in 1995, this collection now contains 6407 interlinked topic pages divided into a tree of 31 specialty books and 722 chapters. Referral is indicated if buddy taping cannot maintain adequate reduction. Comminution is common, especially with fractures of the distal phalanx. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. Indications. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. Search dates: February and June 2015. Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. Ulnar side of hand. Copyright 2023 American Academy of Family Physicians. 24(7): p. 466-7. If you experience any pain, however, you should stop your activity and notify your doctor. Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Copyright 2023 Lineage Medical, Inc. All rights reserved. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. If this maneuver produces sharp pain in a more proximal phalanx, it suggests a fracture in that phalanx. This website also contains material copyrighted by third parties. Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively, High rates of post-operative infection are common, Open reduction via an approach through the nail bed leads to significant post-operative nail deformity, Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively, Type in at least one full word to see suggestions list, Management of Proximal Phalanx Fractures & Their Complications, Middle Finger, Proximal Phalangeal Head - Bicondylar Fracture - Fixation, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. Fractures of the toes and forefoot are quite common. Injuries to this bone may act differently than fractures of the other four metatarsals. An MRI is performed and selected cuts are shown in Figures B and C. What is this patients diagnosis? Rotator Cuff and Shoulder Conditioning Program. Following reduction, the nail bed of the fractured toe should lie in the same plane as the nail bed of the corresponding toe on the opposite foot. Management is influenced by the severity of the injury and the patient's activity level. A combination of anteroposterior and lateral views may be best to rule out displacement. Treatment is generally straightforward, with excellent outcomes. myAO. Advertisement Almost two-thirds of all bones in the feet belong to the toes; hence the risk of fracture in this part of the foot is much higher than the rest of the foot. The most common injury in children is a fracture of the neck of the talus. Phalanx fractures are classified by the following: Phalangeal fractures are the most common foot fracture in children. Treatment typically includes surgery to replace the fractured bone with an artificial implant, or to install hardware and screws to hold the bone in place. There is typically swelling, ecchymosis, and point tenderness to palpation at the fracture site. Although tendon injuries may accompany a toe fracture, they are uncommon. There are 3 phalanges in each toe except for the first toe, which usually has only 2. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Fracture of the proximal phalanx of the little finger in children: a classification and a method to measure the deformity . Patients with lesser toe fractures with angulation of more than 20 in the dorsoplantar plane, more than 10 in the mediolateral plane, or more than 20 rotational deformity should also be referred.6,23,24. This is called internal fixation. Published studies suggest that family physicians can manage most toe fractures with good results.1,2. She is active in ballet and her pain is exacerbated with push-off and en pointe maneuvers. Which of the following acute fracture patterns would best be treated with open reduction and internal fixation? There is typically focal tenderness, swelling, and ecchymosis at the base of the fifth metatarsal. In most cases, this is done by simply adjusting the direction of traction to correct any shortening, rotation, or malalignment. After that, nonsurgical treatment options include six to eight weeks of short leg nonweight-bearing cast with radiographic follow-up to document healing at six to eight weeks.2,6,20 If evidence of healing is present (callus formation and lack of point tenderness) at that time, weight-bearing activity can progress gradually, along with physical therapy and rehabilitation. Nondisplaced or minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts with less than 10 of angulation can be treated conservatively with a short leg walking boot, cast shoe, or elastic bandage, with progressive weight bearing as tolerated. Minimally displaced (less than 3 mm) avulsion fractures typically require immobilization and support with a short leg walking boot. Referral also is recommended for children with first-toe fractures involving the physis.4 These injuries may require internal fixation. Methods: We reviewed the most current literature on various treatment methods of proximal phalanx fractures, focusing on the indications and outcomes of nonoperative as well as operative interventions. We help you diagnose your Toe fractures case and provide detailed descriptions of how to manage this and hundreds of other pathologies . This procedure is most often done in the doctor's office. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. Pediatr Emerg Care, 2008. The localized tenderness of a contusion may mimic the point tenderness of a fracture. ORTHO BULLETS Orthopaedic Surgeons & Providers Adjacent metatarsals should be examined, and neurovascular status should be assessed. Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). A, Dorsal PIPJ fracture-dislocation. Metacarpal Fractures Hand Orthobullets Fractures Of The Proximal Fifth Metatarsal Radiopaedia Fifth Metacarpal Fractures Statpearls Ncbi Bookshelf Great toe fractures are treated with a short leg walking boot or cast with toe plate for two to three weeks, then a rigid-sole shoe for an additional three to four weeks. J Pediatr Orthop, 2001. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. For several days, it may be painful to bear weight on your injured toe. Diagnosis is made with plain radiographs of the foot. If the bone is out of place, your toe will appear deformed. The fifth metatarsal is the long bone on the outside of your foot. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Most broken toes can be treated without surgery. 3 Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. If no healing has occurred at six to eight weeks, avoidance of weight-bearing activity should continue for another four weeks.2,6,20 Typical length of immobilization is six to 10 weeks, and healing time is typically up to 12 weeks. Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations (Figure 5), displaced intra-articular fractures, and fractures that are difficult to reduce. If an acute subungual hematoma is present (less than 24 hours old), decompression may relieve pain substantially. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for four to six weeks. Returning to activities too soon can put you at risk for re-injury. Epidemiology Incidence Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website. toe phalanx fracture orthobulletsdaniel casey ellie casey. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. Tuberosity avulsion fractures are generally found in zone 1 and do not extend into the joint between the fourth and fifth metatarsal bases (Figures 7 and 9). 2012 Oct; 43 ( 10 ): 1626-32. doi: 10.1016/j.injury.2012.03.010. A 19-year-old cross country runner complains of 3 months of foot pain with running. If the bone is out of place and your toe appears deformed, it may be necessary for your doctor to manipulate, or reduce, the fracture. Spiral fractures often lead to rotation or shortening, and transverse fractures lead to angulation.6. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. If it does not, rotational deformity should be suspected. fractures of the head of the proximal phalanx. The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. Bruising or discoloration your foot may be red or ecchymotic ("black and blue"), Loss of sensation an indication of nerve injury, Head which makes a joint with the base of the toe, Neck the narrow area between the head and the shaft, Base which makes a joint with the midfoot. Because it is the longest of the toe bones, it is the most likely to fracture. Surgical repair is indicated for patients with progressive and persistent symptoms who fail nonoperative management. The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). Hand (N Y). To check proper alignment, radiographs should be taken immediately after reduction and again seven to 10 days after the injury (three to five days in children).4 In patients with potentially unstable or intra-articular fractures of the first toe, follow-up radiographs should be taken weekly for two or three weeks to monitor fracture position. The skin should be inspected for open fracture and if . Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) Kay, R.M. X-rays. Epub 2012 Mar 30. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). Despite theoretic risks of converting the injury to an open fracture, decompression is recommended by most experts.5 Toenails should not be removed because they act as an external splint in patients with fractures of the distal phalanx. (Kay 2001) Complications: If stable, the patient can be transitioned to a short leg walking cast or boot3,6 (Figures 411 and 5). Nail bed injury and neurovascular status should also be assessed.