Phalanges of the Foot

Phalanges of the Foot

Phalangeal fractures of the toes are common in chil­

dren. Many of these fractures are treated symptom­

atically by family or primary care physicians. They are rarely referred to an orthopedic center where they might be included in series reports.

Anatomy and Growth

Foot phalanges, like metatarsals, have epiphyses and physes at each end, but typically have a secondary center of ossification (SCO) at only one end, or at nei­

ther end. The great toe almost always has two phalan­

ges, each with one SCO proximally. The second, third, and fourth toes, however, usually have three phalan­

ges and rarely two, while the fifth toe has three or two phalanges in nearly equal frequency. There may be no SCO for the middle phalanx of the third, fourth, and fifth toes, and for the terminal phalanx of toes with two phalanges [2, 11, 15, 16]. These phalanges grow from the physis at each end of the primary os­

Contents

Anatomy and Growth .. . . .411 Classification ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...414 Epidemiology .. . . ..414 Literature.... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...414 Olmsted.County.Study. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .414 Evaluation . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .415 Management ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...415 Complications . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .415 Growth.Arrest. .. . . ..415 Osteomyelitis. ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...415 Joint.Stiffness.... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ...415 Tendon.Rupture. .. . . ..415 Refracture... . . ..418 References . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .418

sification center and do not form a separate SCO [11].

The middle phalange of the 5th toe does not develop an ossified epiphysis at either end in 95% of individu­

als [2].

Secondary centers of ossification appear roentgen­

ographically at different times in each phalanx in each toe (Fig. 14.1). In the great toe the distal phalanx SCO appears first between 8 and 21 months, and the proximal phalanx later, between 15 and 36 months.

In the lateral four toes the opposite is true; the SCO of

Fig. 14.1

Age.of.appearance.of.secondary.centers.of.ossification.

of.foot.phalanges .m.months

the proximal phalanges appear first, between 9 and 36 months, and of the distal phalanges between 24 and 36 months. The order of appearance of proximal phalangeal SCO is third toe, fourth toe, second toe, and fifth toe. The order of appearance of the SCO of the distal phalanges is the fourth toe, third toe, sec­

ond toe, and fifth toe. The SCO of all phalanges ap­

pear a few months earlier in girls [11]. Multiple cen­

ters of ossification are common initially and coalesce into one center early [13].

The physes are typically flat and transverse. How­

ever, those of the proximal phalanges vary consider­

ably in shape, from flat to cone shaped with the apex projecting distally into an accommodating crater of the metaphysis (Figs. 14.2a, b, 19.3a, b, 19.4a, b). These conic epiphyses occurred in 7% of 882 boys, and in 21.5% of 752 girls, aged 4–16 years [14]. They occur

preferentially in the middle toe, and then in each ad­

jacent toe on one or both sides of this toe. Conic phy­

ses fuse relatively early (Fig. 14.2c) [14], with subse­

quent normal anatomy (Figs. 14.2c, 19.3c, 19.4c). They should not be confused with injury or sequelae of injury.

Another normal variant of development is a sa­

gittal cleft in the epiphysis of the proximal phalanx of the great toe (Fig. 14.3). The incidence of this vari­

ant is unknown, but obviously a good history and physical examination are needed to differentiate it from a type 4 fracture. The nuances of the bracket epiphysis (Fig. 14.4) must be known, particularly early in life, to avoid confusion with fracture. Without treatment, this abnormal variant results in deformity with growth.

Fig. 14.2

Normal.cone.shaped.phalanges.in.a.6.year.2.month.old.

female .a.On.the.AP.roentgenogram.the.great.toe.prox- imal.and.distal.and.little.toe.proximal.phalangeal.phy- sis.are.flat.and.normal .The.proximal.phalangeal.physes.

of.the.middle.three.toes.are.cone.shaped.and.could.be.

mistaken.for.fractures.or.partial.arrests .The.remaining.

phalangeal.physes.are.oblique.to.the.plane.of.the.x-ray.

and. cannot. be. adequately. evaluated .b. The. oblique.

view.shows.cone-shaped.proximal.phalangeal.physes.

of. the. middle. three. toes. (arrows) .c. At. age. 13.years.

0.months. all. physes. are. closed. and. all. phalanges. are.

normal

Fig. 14.3

Sagittal.cleft.epiphysis,.proximal.phalanx.right.great.toe.in.a.11.year.7.month.old.boy .There.was.no.history.of.injury.

and.physical.examination.was.normal .a.The.cleft.(arrow).at.age.11.years.7.months .b.The.cleft.was.still.present.at.age.

13.years.3.months .Note.the.absence.of.a.SCO.for.the.fifth.toe.middle.phalanx

Fig. 14.4

Bracket.epiphysis.(arrows).of.the.middle.phalanx.of.the.fourth.toe.in.a.10.year.11.month.old.boy

The extensor digitorum longus inserts primarily into the dorsum of the epiphysis of the distal phalanx, while the flexor digitorum inserts primarily into the metaphysis of volar aspect (Fig. 14.5a). Thus type 2 and 3 fractures are likely with plantarflexion injuries (Fig. 14.5b), but not with dorsiflexion injuries.

Fractures of the distal phalanx, especially of the great toe are often compound. This is explained by close relationship between the bone and proximal portion of the nail, the same as in the thumb (Fig. 9.5).

At the root of the nail, the dermis of the skin is at­

tached directly to the periosteum without any inter­

vening subcutaneous tissue. This area is directly dor­

sal to the physis of the phalanx. Because of this relationship, any fracture through the physis is very likely to extend through the adjacent skin, creating an open fracture. The chance of contamination is greater if the child is barefoot [10, 12].

The foot matures relatively early compared with the remainder of the extremities. Physiologic closure of physes is similar for proximal, middle, and distal

phalanges. In girls the closure rate is 5% at age 11 years, 25% at age 12 (Fig. 19.4c), 50% at age 13 (Figs. 14.2c, 19.3e), and 80% at age 14. In boys the closure rate is 5% at age 13 years (Fig. 19.5d), 20% at age 14, and 35%

by age 15 years [14].

Classification

The same six type anatomic classification (Fig. 3.6) used at other sites is applicable to the phalanges of the toes.

Epidemiology Literature

No physeal fractures of toe phalanges were reported in series prior to 1970 (Table 4.5) [8]. Fifty­seven frac­

tures reported between 1970­1990 accounted for 5%

of all physeal fractures (Table 4.6) [5, 7, 8]. Shoewear undoubtedly protects the toes from injury. Most stud­

ies do not document the presence or absence of shoes at the time of injury [1, 4, 5, 7, 8, 12]. There is specula­

tion that these fractures are more common in the summer when shoes are worn less [4]. There are no reports of these fractures from parts of the world where shoes are rarely worn.

The entity known as the “stubbed great toe” [4, 6, 10, 12] typically occurs when the child is barefoot.

This fracture occurs with forceful plantarflexion, usually when the unprotected toe strikes an object (Fig. 14.5b), and is typically a type 2 [3, 6, 12] or type 3 [10] fracture. The metaphyseal fragment of type 2 fractures is usually small. The largest series is 6 cases [10] (4 boys 2 girls, ages 7–14 years, all barefoot at time of injury, and all type 3 fractures).

Olmsted County Study

Toe phalanges ranked sixth in overall frequency ac­

counting for 6% of all physeal fractures (Table 4.12) [9]. There were 55 fractures in 37 males and 18 females. The ages in boys ranged from 5 through 17 years (peak age 10 years), and in girls from 6 through 15 years (peak age 10 years). There were 7 type 1, 30 type 2, 6 type 3, 8 type 4, 4 type 5, and no type 6. It is suspected that had types 1 and 6 been identified and documented prior to the study that the numbers would have been greater, particu­

larly type 1.

Fig. 14.5

Great. toe. showing. insertion. of. extensor. and. flexor.

digitorum.longus.tendons.in.the.distal.phalanx .a.Nor- mal.toe .b.Distal.phalanx .“Stubbed.toe,”.type.3.frac- ture

Evaluation

Swelling, deformity, and tenderness will vary greatly with the severity of fracture. Nailbed injuries are common with fractures of the distal phalanx, partic­

ularly the great toe. Bleeding from the eponychium or a laceration proximal to the nailbed are signs of an open fracture [3, 10]. Any nail or nailbed injury sus­

tained as a result of a flexion injury should have roentgenograms [6]. AP and lateral views are suffi­

cient for diagnosis. No other imaging has been sug­

gested in the literature.

Occasionally children will first present for care 5–14 days post injury with purulent drainage around the eponychium. Soft tissue swelling combined with roentgenographic resorption of bone and periosteal new bone formation confirm the diagnosis of osteo­

myelitis. Technetium bone scanning would be posi­

tive [12], but usually the diagnosis can be made with­

out it.

Management

Closed fractures rarely require reduction (Fig. 19.5) [3]. Type 1 fractures of the lesser toes (Fig. 14.6a, b) and great toe (Fig. 14.7a) are common. Taping the toe to one or both adjacent toes almost universally results in a well­aligned and well­healed fracture in 3–

4 weeks (Figs. 14.6c, 14.7b). A hard­soled shoe with the dorsum of the toe portion removed is sufficient for weightbearing.

Fractures that would benefit from reduction are those with intra­articular displacement (types 4 and 5) involving more than 25% of the articular surface, those with more than 2 mm displacement, and mark­

edly angulated fractures of any type (Fig. 14.8) [3]. If reduction is unstable it may be maintained by percu­

taneous pinning [3]. If reduction is incomplete or not maintained ORIF is appropriate [1]. Type 5 fractures of toe phalanges (Fig. 14.9) are rare; the only case re­

ported in the literature was in the great toe treated by ORIF [1].

Open fractures require irrigation, debridement, and antibiotics [4, 6, 10]. Nailbed injuries involving the germinal matrix should be repaired [3, 4]. The in­

jured toe should be soaked in a warm water and anti­

infection solution until the skin of the foot wrinkles, three times a day for one week, to extract any pus [4].

Early detection and treatment of these injuries may

reduce or eliminate hospitalization and prolonged in­

travenous antibiotic treatment for osteomyelitis [4].

The “stubbed great toe” (Fig. 14.5b), particularly if compound, is best protected by a short leg walking cast with a toe plate extension or bumper guard.

Complications

No complications of foot phalangeal physeal fracture were recorded in the Olmsted County study (Ta­

ble 8.1) [9].

Growth Arrest

Growth arrest when it occurs is usually complete, but significant relative shortening is uncommon. Even when arrest occurs in the great toe, the relative short­

ening or deformity is minor, rarely elicits comment by the patient, and there are no reports of treatment. In the stubbed great toe syndrome partial arrest on the volar aspect has been noted [4, 6]. These cases have not resulted in clinical problems, probably because most of these patients are teenagers and have little growth remaining. Permanent nail deformity is, how­

ever, the rule [6].

Osteomyelitis

Osteomyelitis of the distal phalanx typically occurs only after an open fracture not treated initially with irrigation, debridement, and antibiotics [4, 6, 10, 12].

When this occurs aspiration and culture, irrigation, debridement, and in­patient intravenous antibiotics provide the best chance for rapid resolution [4].

Growth arrest accompanies such osteomyelitis, but no residual deformities have required treatment [4].

Joint Stiffness

Mild degrees of loss of motion of the joint adjacent to the physeal fracture may be common, but is rarely no­

ticed by the patient and is infrequently recorded in the literature [6]. It rarely, if ever, affects function.

Tendon Rupture

Associated disruption of the extensor hallucis longus

tendon was noted in one patient [6] and treated by

splinting the toe in dorsiflexion. The patient regained

complete active extension.

Fig. 14.6

É Fig. 14.6

Fourth.toe.proximal.phalanx.type.1.fracture .This.11.year.1.month.boy.struck.his.toes.against.a.table.leg.while.dancing.

barefoot .a.A.fracture.of.the.metaphysis.of.the.fourth.toe.extends.proximally.to.the.physis .The.epiphysis.is.not.dis- placed.on.the.metaphysis .b.Oblique.view.confirms.a.transmetaphyseal.fracture .The.fourth.toe.was.taped.to.the.third.

toe.for.11.days .c.Four.months.post.fracture .The.fracture.is.healing.with.transmetaphyseal.sclerosis .Note.absence.of.a.

SCO.for.the.middle.phalanges.of.the.fourth.and.fifth.toes

Fig. 14.7

Great.toe.proximal.phalanx.type.1.frac- ture,. in. a. 14.year. 5.month. old. boy . . a. Type.1. longitudinal. cortical. surface.

fracture. of. the. metaphysis. extends.

proximally. to. the. physis. (arrows) . The.

major.portion.of.physis.is.undisturbed;.

therefore. this. is. not. a. type.2. fracture . The.great.and.second.toes.were.taped.

together. for. 7.days . b. Four. weeks. . later,. transmetaphyseal. sclerosis. (ar- rows).confirms.compression.component.

of.the.type.1.fracture

Fig. 14.8

Little.toe.proximal.phalanx.type.2.fracture .This.9.year.3.month.old.girl.fell.while.doing.a.handstand .a.Type.2.fracture.

proximal.phalanx,.little.toe,.with.30°.angulation .b.Closed.reduction.(incomplete),.held.with.tape.to.fourth.toe .c.Three.

years.one.month.later,.age.12.years.4.months .The.fracture.was.healed.and.the.physis.was.closing.normally

Refracture

Refracture in one case [6] may have been associated with soft tissue interposition or nonunion.

References

1. Buch BD, Myerson MS: Salter­Harris type IV epiphyseal fracture of the proximal phalanx of the great toe: A case report. Foot Ankle Int 16:216­219, 1995

2. Flecker H: The time of appearance and fusion of ossifica­

tion centers as observed by roentgenographic methods.

Am J Roentgenol 47:97­159, 1942

3. Kay RM, Matthys GA: Pediatric foot fractures: Evaluation and treatment. J Am Acad Orthop Surg 9:268­278, 2001

4. Kensinger DR, Guille JT, Horn BD, Herman MJ: The stubbed great toe: Importance of early recognition and treatment of open fractures of the distal phalanx. J Pediatr Orthop 21:31­34, 2001

5. Mizuta T, Benson WM, Foster BK, Patterson OL, Morris LL: Statistical analysis of the incidence of physeal injuries.

J Pediatr Orthop 71:518­523, 1987

6. Noonan KJ, Saltzman CL, Dietz FR: Open physeal frac­

tures of the distal phalanx of the great toe. A case report.

J Bone Joint Surg 76A:122­125, 1994

7. Ogden JA. Injury of the growth mechanism of the imma­

ture skeleton. Skel Radial 6:237­253, 1981

8. Peterson CA, Peterson HA: Analysis of the incidence of in­

juries to the epiphyseal growth plate. J Trauma 12:275­281, 9. Peterson HA, Madhok R, Benson JT, Ilstrup DM, Melton 1972 III LJ: Physeal fractures: Part 1. Epidemiology in Olmsted County, Minnesota, 1979­1988. J Pediatr Orthop 14:423­

430, 1994 Fig. 14.9

Great.toe.proximal.phalanx.type.5.fracture .This.9.year.0.month.old.boy.stubbed.his.right.great.toe.on.a.stair .a.There.

is.a.fracture.of.the.epiphysis.of.the.proximal.phalanx.of.the.great.toe,.type.undetermined .b.Oblique.view.shows.a.

metaphyseal.fragment.confirming.a.type.5.fracture .Treatment.consisted.of.a.short.leg.walking.cast.supporting.the.toe.

for.four.weeks .c.Five.years.1.month.later,.age.14.years.1.month .Normal.anatomy.and.growth .d.Oblique.view,.compare.

with.b .Note:.Was.this.result.good.luck?.ORIF.would.have.been.chosen.by.many.treating.physicians

10. Pinckney LE, Currarino G, Kennedy LA: The stubbed great toe: A cause of occult compound fracture and infec­

tion. Radiology 138:375­377, 1981

11. Pyle I, Sontag LW: Variability in onset of ossification in epiphyses and short bones of the extremities. Am J Roent­

genol 49:795­798, 1943

12. Rathore MH, Tolymat A, Paryani SG: Stubbed great toe in­

jury: A unique clinical entity. Pediatr Infect Dis J 12:1034­

1035, 1993

13. Roche AF, Sunderland S: Multiple ossification centres in the epiphyses of the long bones of the human hand and feet. J Bone Joint Surg 41B:375­383, 1959

14. Venning P: Radiological studies of variation in ossifica­

tion of the foot. III. Cone shaped epiphyses of the proximal phalanges. Am J Phys Anthropol 19:131­136, 1961 15. Venning P: Radiological studies of variations in the seg­

mentation and ossification of the digits of the human foot.

I. Variations in the number of phalanges and centers of ossification of the toes. Am J Phy Anthropol 14:129­152, 16. Venning P: Sib correlations with respect to the number of 1956 phalanges on the fifth toe. Ann Eugen London 18:232­254, 1954