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Displaced Intra-articular Fractures of the Great Toe in Children: Intervene With Caution!

Kramer, Dennis E. MD; Mahan, Susan T. MD, MPH; Hresko, Michael Timothy MD

Journal of Pediatric Orthopaedics: March 2014 - Volume 34 - Issue 2 - p 144–149
doi: 10.1097/BPO.0000000000000110

Background: Intra-articular fractures of the proximal phalanx of the great toe in children are extremely rare and sparsely reported in the literature. We have noted a series of these fractures at our institution. The purpose of this report is to present a retrospective case series of children with intra-articular fractures managed operatively in order to highlight the inherent difficulties in managing these fractures.

Methods: Operative notes and billing records were searched from 2001 to 2011 to identify all children aged 18 years or younger who underwent surgical intervention for an intra-articular fracture of the proximal phalanx of the great toe. Charts and imaging studies were retrospectively reviewed to identify the mechanism of injury, fracture classification, operative details, clinical results, and complications.

Results: Seven boys and 3 girls with a mean age of 12.6 years (range, 8.7 to 15.7 y) were identified. The mechanism of injury was a direct blow from a stubbed toe (8 cases) or a dropped object onto the foot (2 cases). There were 7 intra-articular fractures of the proximal phalanx base, 4 of which occurred in the setting of an open physis. Mean fracture displacement was 4.4 mm. Open reduction was necessary in 9 cases, with K-wire fixation used in 9 cases. Median follow-up was 50.5 months (range, 11 to 123 mo). Seven fractures healed at a mean of 7.9 weeks. Nine patients returned to full activity without limitation at latest follow-up. Six patients had significant complications: 2 underwent revision open reduction internal fixation (one for postoperative redisplacement and the other for painful nonunion), 1 suffered a refracture, 1 developed posttraumatic arthritis requiring interphalangeal joint fusion, 1 developed an asymptomatic fibrous nonunion with avascular necrosis of the fragment, and 1 had K-wire migration necessitating early surgical removal.

Conclusions: Intra-articular fractures of the great toe primarily occur in adolescents after direct impact injuries. The most common location was the proximal phalangeal base. There is a high complication rate after surgical intervention, although most patients were asymptomatic at latest follow-up.

Level of Evidence: IV (retrospective case series).

Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA

No support was obtained for this manuscript.

The authors declare no conflicts of interest.

Reprints: Dennis E. Kramer, MD, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115. E-mail:

© 2014 by Lippincott Williams & Wilkins