Foot Trauma, fracture of the interphalangeal joint of the great toe:
Today I’d like to tell you about a foot trauma case. A young lady presented to my office with a chief complaint of pain in her right great toe. She stated that two days prior she fell off her bicycle. She said the pain was not terrible however when she looked at her foot her great toe was bent at 90° at the joint in a direction where it usually does not go. She quickly grabbed the toe and popped it back into place. She then had increased pain. She says that the toe swelled up immediately after her fall.
Physical examination revealed an extremely swollen and bruised right great toe with severe pain to palpation. I checked to make sure there was good blood flow by pressing on the distal aspect of the toe and noted that the color blanched and came back within 3 seconds. She also had normal feeling in the tip of the toe indicating that there was no nerve injury.
Her x-ray (seen below) showed a mildly displaced fracture of the distal phalanx of the great toe. She did an excellent job at putting the toe back into position from the dislocated joint. This joint, is called the interphalangeal joint. (Intra-articular, mildy displaced fracture of distal phalanx of hallux) (click and any picture to enlarge)
Treatment: I immobilized her in a fracture brace that she will wear for 4-6 weeks. Had she not reduced the dislocation I would have given her local anesthesia and popped it back into place in my office. I advised her that since the fracture enters the joint that she may experience osteoarthritis in this joint at some time in the future.
When a fracture enters the joint it disrupts the cartilage on the end of the bone. When you having injury to the cartilage over time it may wear away and cause arthritis such that the two bones grind together. If this is the case, she will most likely require surgical intervention. In that case what I do is remove the cartilage completely from both bones and fuse the joint with a screw. When the two bones heal they become one bone. When people have arthritis joint fusions are very often used to alleviate the pain. In theory, if there is no motion at the joint then there is no pain at the joint.
The below picture is not of this patient, however, this is what a joint fusion (arthrodesis) with headless screw of the interphalangeal joint looks like:
I have caused much trauma to this joint from years of dancing (i still dance for a living), being en pointe shoes, as a distance runner in shoes that were snug, and as a flamenco dancer for 7 years. i am in arthritic pain, and in my line of work, i still must wear heels from time to time. both feet have bunions, and the left (the trauma joint), also as has a calcium build-up on the top of the foot – not just the side part of the bunion. I had x-rays done and the joint has a jagged edge where i have killed the bone, and the bone is calcifying and growing toward my second toe.
you write above on how you fuse the bone together, what does that mean for a dancer? is all mobility lost? would one ever be able to stand on their “tippy-toes”? what does that mean for a heel wearing client?
please give me a rundown.
Thanks ever so much,
Dani
Hi Dani, in my experience, dancers hasthe worst feet, especially on point. From what you described, it sounds like you have bone spurs on the top of the joint. This Thomas from repetitive trauma such as running or dancing. With some people, I am able to just remove the spurs and let the toe moved again. If there is significant arthritis and the cartilage is damaged, then it requires a more invasive procedure to remove the joint. This entails either resecting part of the bone to create a space or fusingthe joint. If you fuse the joint the big toe joint it will never move again. This makes it difficult to wear heels, or dance. Unfortunately, I cannot recommend this procedure without and examination and x-rays.
Hi Dr. Silverberg,
In July 2010 I had a similar injury to the patient you describe above. A fall off my bike broke the distal phalanx of my right great toe. Unfortunately, the fracture entered my interphalangeal joint as well however the fracture was not displaced. I got xrays and saw a DPM. No surgery was recommended. He put me in a hard soled boot for six weeks and told me not to run for 10 weeks. I’m 32, very active (big runner and cyclist) and was very concerned that this would limit my activities. I was told of the potential for osteoarthrits and perhaps fusion down the road.
Today the toe is still painful. It’s a constant bother even while walking a few blocks. I have regained complete control and range of motion of the toe, however it feels like there is a bump under the toe- it doesn’t lay flat comfortably. I can still run and bike, but do so with constant discomfort. The joint space shows some arthritic change on xray btw. A cortisone shot eased the pain for a couple months, but now it hurts again. My DPM tells me nothing more can be done and suggests continued cortisone injections. I have no interest in a fusion at my age. Is there really nothing else that modern medicine has to offer? I’ve been reading up on stem cell injections lately- any thoughts on that as an alternative treatment? Do you have any other thoughts on what might be done? Thanks very much for the help.
Hi Adam.
I agree with your treatment so far. If the bones were not displaced then surgery is not indicted in the acute injury. I always tell patients with intraarticular fracture, fractures that enter a joint, that they most likely will have arthritis in the future and need sugery.
Cortisone type injections will sometimes work for long periods or permanently but often only last a short period of time. The use of repeated steroid injections has many risks of atrophy and ruptures.
At this time it sounds like you need a joint fusion. Fortunaltely, it is your ineterphalangeal joint and not your metatarsal phalangeal joint. The IP joint fusion has very little effect on running and cycling. The IP joint doesn’t bend much because the big toe is flat on the ground and doesnt bend into the ground.
Good luck.
Dr. S.
I stubbed my left toe on first base and it hurt like hell! I did this about 2-3 months ago. Xrays were negative for any fracture. The first joint (under the nail bed) is still very sore. I cannot bend my toe very well, as one would to scrunch up the toes. If my foot slides slightly in my shoes, the toe hurts a lot! I can easily run – the bending motion of the toe to run does not hurt at all. How long does it take for a stubbed toe to feel better? It’s been a long time and it is still sore (annoying for someone who enjoys playing softball – I’m scared of stubbing into a base again!)
Hi Kat.
It usually takes four to six weeks for injuries such as yours to heal. If you do not treat an injury with immobilization sometimes they do not heal. Other times the injury heals and the inflammations continues after the healing is done. When this occurs, sometimes a well placed steroid injection works to alleviate the pain. However, injecting steroid into a non healing injury can actually make it worse. You should go see a doctor to reevaluate.
Hi Dr.- I am a 60 y/o nurse who spends a great.deal of time standing. I am also athletic. I am having a great deal of pain just walking in that joint. even the weight of the bed covers hurts.
I saw a podiatrist who xrayed both feet and said that I have bunions although my pain is not in the bunion area, but in the IP joint itself. The IP joint is jagged and he was not surprised that I was having pain. Interestingly enough, there is no swelling or redness over the joint. He thinks that the bunion issue has influenced the IP joint issues.
I really do not want surgical intervention to the bunion especially if it does not bother me. Is it possible to clean up the joint like I have had to do with my knees and hips bilaterally? Are cortisone injections ever used? Actually, injections were never beneficial in my other joints. It was just a “bandaid” and I ended up having to have surgical intervention.
Thank you doctor.
Hi Candace,
Without examining you and seeing X-rays it is a little difficult to comment. However, I can try to generalize.
If the bunion is not causing the pain then you probably do not need to address it assuming all if the pain is comming from the interphalangeal joint.
Injections into the IP joint will be temporary if they even work at all. In my experience the best way to resolve arthritic pain of the IP joint is to fuse it. Cleaning it up, called a cheilectomy procedure, only works when the cartilage is intact and there are just external spurs on the joint. Sounds like this does not apply to you as you described it as jagged.
Fusion of the IP Joint involves removing the cartilage remaining and some bone and fixating with a screw.
Recovery is even less than a bunion surgery.
Good luck.
Hi Dr. Silverberg,
I had an akward fall at home and have a fracture in my big toe. Is it typically better to immobilize it for the best chance of healing? I’m confused because when I was first seen at a local hospital a senior doctor put me in a short cast which was temporary until the swelling came down and referred me to the fracture clinic for a new cast after about 7 days. At the fracture clinic the doctor recommended to go ahead and walk on it and leave it buddy taped. It’s been just over three weeks and is still painful to walk.
The Dr’s report here said ” mildly displaced fracture of the distal phalax measuring 3 mm. It is intra articular.”
Are the any questions I could ask on my next follow up? Is it best to keep it taped or any other suggestions? I’m 38 years old, am active and play soccer.
Hi Andrew.
Every fracture needs to be immobilized in order to heal.
Picture your body producing new hard bone in order to repair the fracture. Bone is a hard brittle substance. If you produce more bone and then move it, it will crack the new bone that has formed. This is the most important thing in fracture healing. Immobilization for four to six weeks as much as possible for any part of the body.
In the foot, immobilization consists of casts or braces or taping and sometimes non-weight-bearing with crutches.
Intra articular means the fracture entered a joint which has a greater chance of arthritis in the future due to cartilage injury.
Dr. S.
Hi Dr. Silverberg,
As it turns out I’ve got a bunion with hallux rigidus (have a dorsal spur as well) on my left foot. I still have ~ 30 degrees of dorsiflexion on this toe. I’m feeling pain from my bunion while walking or standing. A couple of months ago I noticed that IP joint on the same toe become quite painful and got spurs as well (have no more than 10 degrees of flexion in this joint). What is the best possible treatment in my situation? Can both IP and MTP joints be fused?
Thank you for help.
Hi Dr. Silverberg,
I hyperflexed my toe a week ago as I slipped in the bathroom. Some bruising appeared on the superior surface just distal to the IP joint, it swelled a bit, and it hurt A LOT. I’ve been icing, elevating, and wrapping the toe and was taking diclofenac sodium but had an allergic reaction so stopped the NSAIDs. The toe is looking less swollen, and pinching the proximal & distal phalanxes produces no pain (except right over the swollen/bruised area). My concern is that I can’t seem to flex the IP joint at all, could this just be splinting from the swollen tissue or should I be concerned? I am living outside the US and don’t have easy access to X-ray so I’m trying to gauge whether its worth going through a lot of trouble to get it checked out.
I realize this article is old but you generously answered some other questions so I’m hoping for the same!
Thanks
I had a misunderstanding with an elliptical machine and fractured my right big toe into the joint, the first joint. My doctor suggested taping it and putting it up for a few days and gave me some tramadol. Taping it just hurts too much, but without taping it it’s just bare, he didn’t give me any sort of cast, boot, shoe, etc. He had also told me about the possibility for early onset arthritis due to the break into the joint, but since there is no displacement that I shouldn’t need a pin. Would you suggest any different sort of treatment? I am also a very active woman and at 28-29 I dont want to be out of commission for weeks on end. What excersizes can I do and how early can I start? I’m only on day 2 since the break and already the swelling is remarkably better, though it still aches and is stiff.