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). If the bone is out of place, your toe will appear deformed. Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured. Tang, Pediatric foot fractures: evaluation and treatment. Treatment Most broken toes can be treated without surgery. Early surgical management of a Jones fracture allows for an earlier return to activity than nonsurgical management and should be strongly considered for athletes or other highly active persons. Surgery may be delayed for several days to allow the swelling in your foot to go down. Patients with circulatory compromise require emergency referral. Your foot may become swollen and discolored after a fracture. (OBQ12.89) 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). Patients with intra-articular fractures are more likely to develop long-term complications. Diagnosis requires radiographic evaluation, although emerging evidence demonstrates that ultrasonography may be just as accurate. A positive metatarsal loading test, which involves manual axial loading of the metatarsal, may exacerbate the pain and help differentiate a fracture from a soft tissue injury.3. Approximately 10% of all fractures occur in the 26 bones of the foot. Pediatrics, 2006. 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. 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. This is called internal fixation. (Left) The four parts of each metatarsal. To unlock fragments, it may be necessary to exaggerate the deformity slightly as traction is applied or to manipulate the fragments with one hand while the other maintains traction. Although tendon injuries may accompany a toe fracture, they are uncommon. Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury. Stress fractures can occur in toes. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Returning to activities too soon can put you at risk for re-injury. A Jones fracture has a higher risk of nonunion and requires at least six to eight weeks in a short leg nonweight-bearing cast; healing time can be as long as 10 to 12 weeks. (OBQ09.156) Ulnar side of hand. Bony deformity is often subtle or absent. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. The injured toe should be compared with the same toe on the other foot to detect rotational deformity, which can be done by comparing nail bed alignment. The nail should be inspected for subungual hematomas and other nail injuries. Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. Fractures of multiple phalanges are common (Figure 3). 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. Although adverse outcomes can occur with toe fractures,3 disability from displaced phalanx fractures is rare.5. Content is updated monthly with systematic literature reviews and conferences. Bite The Bullet, He Needs Long Term Function: Be The Hated Person - Robert Anderson, MD. Metatarsal shaft fractures are initially treated with a posterior splint and avoidance of weight-bearing activities; subsequent treatment consists of a short leg walking cast or boot for four to six weeks. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. While many Phalangeal fractures can be treated non-operatively, some do require surgery. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. Three muscles, viz. Started in 1995, this collection now contains 6407 interlinked topic pages divided into a tree of 31 specialty books and 722 chapters. The fifth metatarsal is the long bone on the outside of your foot. During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. While many Phalangeal fractures can be treated non-operatively, some do require surgery. Most patients with acute metatarsal fractures report symptoms of focal pain, swelling, and difficulty bearing weight. He came to the ER at that point to be evaluated. These bones comprise 2 bones in the hindfoot (calcaneus, talus), [ 1, 2] 5 bones in the midfoot (navicular, cuboid, 3. A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for four to six weeks. 2017 Oct 01;:1558944717735947. Foot fractures range widely in severity, prognosis, and treatment. Nondisplaced tuberosity avulsion fractures can generally be treated with compressive dressings (e.g., Ace bandage, Aircast; Figure 11), with initial follow-up in four to seven days.2,3,6 Weight bearing and range-of-motion exercises are allowed as tolerated. 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. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. The "V" sign (arrow) indicates dorsal instability. Epidemiology Incidence laceration bone talks, extensor tendon injuries hand orthobullets, flexor and extensor tendon injuries phoenix az arizona, tendon lacerations twin boro physical therapy, repair and rehabilitation of extensor hallucis longus and, extensor mechanism injury hip amp knee book, Patients with unstable fractures and nondisplaced, intra-articular fractures of the lesser toes that involve more than 25 percent of the joint surface (Figure 3) usually do not require referral and can be managed using the methods described in this article. A fractured toe may become swollen, tender, and discolored. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) When performed on 18 children with distal radius-ulna fractures, P_STAR achieved near anatomic fracture alignment with no nerve or tendon injury, infection, or refracture. hand fractures orthoinfo aaos metatarsal fractures foot ankle orthobullets phalanx fractures hand orthobullets fractures of the fifth metatarsal physio co uk 5th metatarsal . Vollman, D. and G.A. 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). 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). ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. Hatch, R.L. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. Epidemiology Incidence High-impact activities like running can lead to stress fractures in the metatarsals. Unlike an X-ray, there is no radiation with an MRI. A fractured toe may become swollen, tender, and discolored. Patients with open toe fractures or fractures with overlying skin necrosis are at high risk for osteomyelitis. Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. 118(2): p. e273-8. Healing rates also vary considerably depending on the age of the patient and comorbidities. They most often involve the metatarsals and toes. Metatarsal shaft fractures near the head or base of the first to fourth metatarsal with any degree of displacement or angulation are often associated with concomitant injuries and generally take longer to heal. The video will appear on the video dashboard once complete. Most fifth metatarsal fractures can be treated with weight bearing as tolerated, and immobilization in a cast or walking boot. Proximal phalanx (finger) fracture Contents 1 Background The flexor digitorum superficialis (FDS) inserts at the middle of the phalanx and can cause rotational deformity [1] Extensor tendons and interosseous muscles commonly causes volar angulation [1] Clinical Features Finger pain Differential Diagnosis Hand and Finger Fractures Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. The pull of these muscles occasionally exacerbates fracture displacement. Initial follow-up should occur within one to two weeks, then every two to four weeks for a total healing time of four to six weeks.6,23,24 Radiographic follow-up in seven to 10 days is necessary for fractures that required reduction or that involve more than 25% of the joint.6, Indications for referral of toe fractures include a fracture-dislocation, displaced intra-articular fractures, nondisplaced intra-articular fractures involving more than 25% of the joint, and physis (growth plate) fractures. 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. Taping may be necessary for up to six weeks if healing is slow or pain persists. If an avulsion fracture results in a large displaced fracture fragment, however, your doctor may need to do an open reduction and internal fixation with plates and/or intramedullary screws. 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. The flexor and extensor tendons impart a longitudinal compression force, which can shorten the phalanx and extend the distal fragment [ 1 ]. Radiographs often are required to distinguish these injuries from toe fractures. Metacarpal Fractures Hand Orthobullets Fractures Of The Proximal Fifth Metatarsal Radiopaedia Fifth Metacarpal Fractures Statpearls Ncbi Bookshelf Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. (Left) In this X-ray, a fracture in the proximal phalanx of the fifth toe (arrow) has caused the toe to become deformed. These tendons may avulse small fragments of bone from the phalanges; they also can be injured when a toe is fractured. The fractures reviewed in this article are summarized in Table 1. Injuries to this bone may act differently than fractures of the other four metatarsals. This information is provided as an educational service and is not intended to serve as medical advice. Objective Evidence 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! Thus, this article provides general healing ranges for each fracture. Physical examination reveals marked tenderness to palpation. (Right) The bones in the angled toe have been manipulated (reduced) back into place. 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. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. More sensitive than an X-ray, an MRI can detect changes in the bone that may indicate a fracture. Physical examination findings typically include tenderness to palpation, swelling, ecchymosis, and sometimes crepitation at the fracture site. Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit. The most common symptoms of a fracture are pain and swelling. 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. Which of the following is responsible for the apex palmar fracture deformity noted on the preoperative radiographs? Therefore, phalanges and digits adjacent to the fracture must be examined carefully; joint surfaces also must be examined for intra-articular fractures (Figure 3). Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. See permissionsforcopyrightquestions and/or permission requests. Proximal articular. 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. Referral is indicated for patients with first metatarsal fractures with any displacement or angulation. Proximal phalanx fractures - displaced or unstable If a proximal phalanx fracture is displaced or if the fracture pattern is unstable it is likely that surgery will be recommended. Distal metaphyseal. Management is determined by the location of the fracture and its effect on balance and weight bearing. 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. However, overlying shadows often make the lateral view difficult to interpret (Figure 1, center). If this maneuver produces sharp pain in a more proximal phalanx, it suggests a fracture in that phalanx. They typically involve the medial base of the proximal phalanx and usually occur in athletes. Proximal interphalangeal joint (PIPJ) dislocation is one of the most common hand injuries. Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. Although often dismissed as inconsequential, toe fractures that are improperly managed can lead to significant pain and disability. Dislocation refers to displacement in which the two articular surfaces are no longer in contact, in contrast to subluxation, in which there is some contact (may be referred to as complete versus simple dislocation in some texts). Because it is the longest of the toe bones, it is the most likely to fracture. Data Sources: We searched the Cochrane database, Essential Evidence Plus, and PubMed from 1900 to the present, human studies only, using the key words foot fractures, metatarsal, toe, and phalanges fractures. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. 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. Surgical repair is indicated for patients with progressive and persistent symptoms who fail nonoperative management. Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. 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. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. . In many cases, a stress fracture cannot be seen until several weeks later when it has actually started to heal, and a type of healing bone called callus appears around the fracture site. Your doctor will then examine your foot and may compare it to the foot on the opposite side. The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. The next bone is called the proximal phalanx. Clin J Sport Med, 2001. Radiographic studies of a toe should include anteroposterior, lateral, and oblique views (Figure 1). 2 ). The proximal fragment flexes due to interossei, and the distal phalanx extends due to the central slip. See permissionsforcopyrightquestions and/or permission requests. Kay, R.M. 50(3): p. 183-6. Epub 2012 Mar 30. If there is a break in the skin near the fracture site, the wound should be examined carefully. In some cases, a Jones fracture may not heal at all, a condition called nonunion. Fracture position ideally will be maintained when traction is released, but in some cases the reduction can be held only with buddy taping. Minimally displaced (less than 3 mm) avulsion fractures typically require immobilization and support with a short leg walking boot. Your doctor will tell you when it is safe to resume activities and return to sports. This webinar will address key principles in the assessment and management of phalangeal fractures. A 55 year-old woman comes to you with 2 months of right foot pain. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Am Fam Physician, 2003. They can also result from the overuse and repetitive stress that comes with participating in high-impact sports like running, football, and basketball. If the wound communicates with the fracture site, the patient should be referred. (OBQ18.111) Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. MB BULLETS Step 1 For 1st and 2nd Year Med Students. Copyright 2016 by the American Academy of Family Physicians. This usually occurs from an injury where the foot and ankle are twisted downward and inward. Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. MTP joint dislocations. Proximal metaphyseal. ORTHO BULLETS Orthopaedic Surgeons & Providers The collateral ligaments and volar plate at the metacarpophalangeal (MCP) joint stabilize the proximal portion and the extensor tendon pulls the distal fragment into extension. Metatarsal shaft fractures most commonly occur as a result of twisting injuries of the foot with a static forefoot, or by excessive axial loading, falls from height, or direct trauma.2,3,6 Patients may have varying histories, ranging from an ill-defined fall to a remote injury with continued pain and trouble ambulating. Note that the volar plate (VP) attachment is involved in the . 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. 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. Indications. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures (Figure 6).4. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. The first toe has only two phalanges; the second through the fifth toes generally have three, but the fifth toe sometimes can have only two (Figure 1). Pediatr Emerg Care, 2008. If it does not, rotational deformity should be suspected. stress fracture of the proximal phalanx MRI indications positive bone scan hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture abnormal radiographs persistent pain, swelling, weak toe push-off not recommended routinely findings will show disruption of volar plate Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). Which of the following acute fracture patterns would best be treated with open reduction and internal fixation? Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Because Jones fractures are located in an area with poor blood supply, they may take longer to heal. There is evidence that transitioning to a walking boot and then to a rigid-sole shoe (Figure 6) at four to six weeks, with progressive weight bearing as tolerated, results in improved functional outcomes compared with cast immobilization, with no differences in healing time or pain scores.12, Follow-up visits should occur every two to four weeks, with repeat radiography at four to six weeks to document healing.3,6 At six weeks, callus formation on radiography and lack of point tenderness generally signify adequate healing, after which immobilization can be discontinued.2,3,6. The same mechanisms that produce toe fractures may cause a ligament sprain, contusion, dislocation, tendon injury, or other soft tissue injury. A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. Copyright 2023 Lineage Medical, Inc. All rights reserved. (OBQ05.209) Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. Management is influenced by the severity of the injury and the patient's activity level. During this time, it may be helpful to wear a wider than normal shoe. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. During the procedure, your doctor will make an incision in your foot, then insert pins or plates and screws to hold the bones in place while they heal. 2017, Management of Proximal Phalanx Fractures & Their Complications, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Proximal Phalanx Fracture: Case of the Week - Michael Firtha, DO, Proximal Phalanx Fracture Surgery by Dr. Thomas Trumble, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. A 34-year-old male sustains the closed finger injury shown in Figure A one week ago. 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. Rotator Cuff and Shoulder Conditioning Program. Examination should consist of a neurovascular evaluation and palpation of the foot and ankle. Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. Fractures of the toes and forefoot are quite common. Management of Proximal Phalanx Fractures Management of Proximal Phalanx Fractures & Their Complications. 68(12): p. 2413-8. X-rays. Patients have localized pain, swelling, and inability to bear weight on the. Posterior splint; nonweight bearing; follow-up in three to five days, Short leg walking cast with toe plate or boot for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to six weeks, Open fractures; fracture-dislocations; intra-articular fractures; fractures with displacement or angulation, Short leg walking boot or cast for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to eight weeks, Open fractures; fracture-dislocations; multiple metatarsal fractures; displacement > 3 to 4 mm in the dorsoplantar plane; angulation > 10 in the dorsoplantar plane, Three-view foot series with attention to the oblique view, Compressive dressing; ambulate as tolerated; follow-up in four to seven days, Short leg walking boot for two weeks, with progressive mobility and range of motion as tolerated; follow-up every two to four weeks; healing time of four to eight weeks, Repeat radiography at six to eight weeks to document healing, Displacement > 3 mm; step-off > 1 to 2 mm on the cuboid articular surface; fracture fragment that includes > 60% of the metatarsal-cuboid joint surface, Short leg nonweight-bearing cast for six to eight weeks; cast removal and gradual weight bearing and activity if radiography shows healing at six to eight weeks, or continue immobilization for four more weeks if no evidence of healing; healing time of six to 12 weeks, Repeat radiography at one week for stability and at the six- to eight-week follow-up; if no healing at six to eight weeks, repeat radiography at the 10- to 12-week follow-up, Displacement > 2 mm; 12 weeks of conservative therapy ineffective with nonunion revealed on radiography; athletes or persons with high activity level, Three-view foot series or dedicated phalanx series, Short leg walking boot; ambulate as tolerated; follow-up in seven days, Short leg walking boot or cast with toe plate for two to three weeks, then may progress to rigid-sole shoe for additional three to four weeks; follow-up every two to four weeks; healing time of four to six weeks, Repeat radiography at one week if fracture is intra-articular or required reduction, Fracture-dislocations; displaced intra-articular fractures; nondisplaced intra-articular fractures involving > 25% of the joint; physis (growth plate) fractures, Buddy taping and rigid-sole shoe; ambulate as tolerated; follow-up in one to two weeks, Buddy taping and rigid-sole shoe for four to six weeks; follow-up every two to four weeks; healing time of four to six weeks, Displaced intra-articular fractures; angulation > 20 in dorsoplantar plane; angulation > 10 in the mediolateral plane; rotational deformity > 20; nondisplaced intra-articular fractures involving > 25% of the joint; physis fractures.