The initial evaluation is directed toward assessing the neurovascular status of the toe or toes and evaluating the degree of tissue compromise and clinical deformity. Two to three radiographic views are adequate to demonstrate the injury in most cases.

The treatment methods of closed digital fractures range from simple protection of the toe to surgical reduction or excision of all or some of the fracture fragments. Treatment of closed digital fractures may be divided into criteria based on several factors, including the following: (a) alignment of the fracture fragments; (b) if malaligned, the possibility that the fragments can be adequately realigned with closed reduction; and (c) the possibility that alignment can be maintained
once the fragments are reduced. Reduction of the fracture is performed in an attempt to prevent shortening, angulation, and rotational malalignment.

Protection alone consists of maintaining stability to the injured region with splintage and immobilization. Comfort and stability may be enhanced by splinting the injured digits to the uninjured neighboring toes with tape, felt, silicone molds, urethane molds, prefabricated digital splints, or other similar materials. This method of splintage is termed buddy splinting (Fig. 103.2). For fractures of the hallux, a gutter splint or toe spica can be formed around the hallux, first MTPJ, and medial aspect of the foot by fashioning a splint made of moldable, rigid material (e.g., cast material) and secured along the medial aspect of the foot with an ACE bandage or other soft dressing (7,8 and 9) (Fig. 103.3). After splintage, the injured foot can be additionally protected with immobilization in a surgical shoe, cast boot, cast, or in a non-weight-bearing position if necessary. Most phalangeal fractures are immobilized in the position of function, and the duration of immobilization is determined by clinical and radiographic evidence of healing. In most cases, consolidation of the osseous fragments develops in 4 to 8 weeks. During this period, the clinician must correlate the clinical findings with radiographic evidence

because fracture lines will remain radiographically visible for several months.

The alignment of the fracture fragments is the key in determining whether reduction is necessary. It is important to understand the principles of closed and open reduction as well as the anatomy and the mechanism of injury if malalignment exists. Bone injury is less significant than the soft tissue disruptions that occur on the convex side of the fracture site. Generally, the soft tissues on the concave side of the injury remain intact. These soft tissue structures guide the fracture fragments into a more normal position and tend to prevent overcorrection during closed reduction by acting as a hinge on the concave surface. Manipulative closed reduction is achieved by exaggerating the plane of deformity, followed by distraction and then reduction. After completion of the reduction, radiographs are taken to assess alignment (Fig. 103.4). The configuration of the fracture may be described as stable, potentially stable, or unstable. Stable, reduced fractures are able to withstand telescoping forces with protection and immobilization and are generally transverse in orientation to the longitudinal axis of the bone or short oblique phalangeal fractures. Stable transverse and short oblique fracture types are usually treated with closed reduction and immobilization and typically respond well and heal without adverse sequelae, unless the injury has an intraarticular component. In this circumstance, the patient may later develop stiffness or painful arthrosis even if healing progresses uneventfully.

Unstable fractures possess minimal intrinsic ability to withstand shortening and consist of long oblique, spiral, and some comminuted fractures. Creating adequate stability may require additional support from external fixation or open reduction with fixation. Kirschner wires (K-wires) can be inserted percutaneously to maintain a fracture that has been realigned with closed reduction. Serial postreduction radiographs or fluoroscopy may be used to ascertain proper placement and reduction. Direct open reduction with K-wire fixation may prove necessary in some instances.

Fractures that are unstable, nonreducible, intra-articular, or associated with coexisting neurovascular compromise need
immediate attention and may require open reduction with fixation for proper alignment and stability. Surgical intervention with open reduction is performed with standard sterile technique and insertion of appropriate hardware as deemed necessary (Fig. 103.5). Achieving proper fixation is required, especially with intra-articular fractures that have a significant potential to develop posttraumatic arthritis, as seen in fractures of the hallux interphalangeal joint or first MTPJ (10,11 and 12) (Fig. 103.6).

In the lesser digits, the concern for complete reduction of the intra-articular components of the fracture is not as great.

Stiffness or arthrosis is generally not as disabling as in the hallux interphalangeal joint, the lesser toes are not subjected to the same degree of weight-bearing stress, and surgical options for repair of these digits are generally easily accomplished. Infrequently, comminuted fractures of the hallux or lesser digits may require excision of the fragments because of the number, smaller size, or nonhealing of the fracture fragments. Excision may be carried out immediately in patients with traumatic open fractures or later with closed fractures if fragments become symptomatic after conservative treatment has failed. If painful arthrosis or malunion of the bone
persists, resectional arthroplasty of the involved joint may be necessary (13).

Even with proper immobilization and fixation, posttraumatic sequelae may occur with digital fractures. Included in the potential long-term problems are delayed union or nonunion of the fractured segments, malunion, chronic pain, and posttraumatic intra-articular arthrosis. In these instances, surgical intervention, possibly including arthroplasty or arthrodesis, may be necessary to obtain pain relief for the patient (10,13,14 and 15).

Open injuries frequently represent a surgical emergency. One should initially evaluate the neurovascular status of the injured part as well as the extent of any soft tissue loss (Fig. 103.7). Bacterial cultures should be taken from the wound and appropriate antibiotic therapy initiated. Multiple radiographs aid in assessing the bone disruption. Thorough irrigation is then necessary to reduce the risk of infection. The wounds may then be evaluated relative to the repair of the osseous injury and soft tissues.