Summary

Fractures of the Hallux (Great Toe) are common injuries resulting from direct trauma (dropping a heavy object) or stubbing (axial load). Unlike lesser toes, the Hallux plays a critical role in Weight Bearing (taking 50% of body weight during push-off) and Balance. Treatment is therefore more aggressive. While non-displaced fractures are treated with rigid splinting, displaced intra-articular fractures require reduction and fixation (K-wires) to prevent Hallux Rigidus (stiff toe). A critical pediatric variant is the Seymour Fracture, which is an open Salter-Harris fracture mimicking a mallet toe. [1,2,3]

Key Facts

• Weight Bearing: The big toe is the final point of contact in the gait cycle. A stiff or painful big toe alters the entire gait, leading to knee and hip pain.
• Seymour Fracture: In children, a "stubbed toe" with a nail avulsion is often an open fracture of the growth plate with the nail fold interposing. This requires antibiotics and washout, or it develops osteomyelitis.
• Nail Bed Injury: A seemingly simple fracture often has a lacerated nail bed underneath. The nail plate acts as a splint.

Clinical Pearls

"Trephinate the Hematoma": A subungual hematoma (blood under the nail) causes throbbing pain due to pressure. You don't need to remove the nail. Just burn a hole in it (hot paperclip or needle) to release the blood. The relief is instantaneous.

"Buddy Strapping is NOT enough": For the big toe, taping it to the second toe offers little stability because the second toe is too small. You need a Rigid Sole Shoe (Post-op shoe) to stop the toe bending.

"Stubbing vs Dropping": "Dropping" usually crushes the distal phalanx (Tuft fracture). "Stubbing" usually fractures the Proximal Phalanx or Neck.

                 HALLUX FRACTURE
                        ↓
             OPEN FRACTURE / SEYMOUR?
            ┌───────────┴───────────┐
           YES                     NO
            ↓                       ↓
    WASHOUT + Abx          INTRA-ARTICULAR
    (Remove Nail?)         & DISPLACED?
            ↓              ┌────────┴────────┐
           K-WIRE         NO                YES
                         (Stable)         (Unstable)
                            ↓                 ↓
                       RIGID SHOE         REDUCTION
                       (4 weeks)          (K-wire)

Indications

• Non-displaced fractures.
• Tuft fractures (comminuted tip).
• Displaced fractures that reduce stable.

Protocol

• Rigid Sole Shoe (Darco): Essential. Prevents MTP extension (push-off) which stresses the fracture.
• Buddy Taping: To 2nd toe (for comfort only).
• Duration: 4-6 weeks.
• Nail Care: If nail is intact, leave it. It's the best splint.

Subungual Hematoma

• Painful: Trephination (drainage).
• Non-painful: Leave alone.
• Old Teaching: "Remove nail if >50% hematoma to check for bed laceration".
• New Teaching: Leave the nail. Repairing the bed adds no benefit if the nail plate is holding it approximated.

Indications

• Displaced Intra-articular: Step-off >2mm (will cause arthritis).
• Unstable: Re-displaces after reduction.
• Open Fracture: Significant contamination.
• Seymour Fracture: Pediatric Salter-Harris I/II with nail fold entrapment.

Technique

• Closed Reduction & Percutaneous Pinning (CRPP):
  • 1.6mm K-wire driven longitudinally from tip of toe across the fracture.
  • Wire removed at 4 weeks.
• ORIF:
  • Mini-plate (2.0mm) for transverse shaft fractures (rarely used, screws preferred).
  • Digital block anesthesia.

Seymour Fracture Protocol

• Recognize: Nail is lifted above the nail fold (avulsed).
• Action: This is an OPEN fracture. The germinal matrix is stuck in the fracture site.
• Procedure: Remove nail. Wash out. Reduce fracture. Antibiotics.

To Pin or Not to Pin?

• Outcome Studies: Show that articular step-offs are basically tolerated poorly in the Hallux (unlike lesser toes). The threshold for surgery is low.

Antibiotics for Phalanx Fractures

• Meta-analysis: For open phalanx fractures with minimal soft tissue injury (e.g., tuft fracture with small wound), prophylactic antibiotics do NOT reduce infection rates significantly if thorough washout is performed.

The Injury

You have broken the main bone of your big toe. This is more serious than breaking a little toe because your big toe carries half your body weight when you walk.

The Plan

• The Shoe: You must wear the ugly flat shoe for 4 weeks. It keeps the toe straight.
• The Nail: It will likely fall off in 3-4 weeks. A new one will grow back, but it takes 12 months and might look a bit wavy.

Surgery?

We need to put a temporary wire in the toe to hold it straight. The wire sticks out the end of your toe. We pull it out in the clinic in 4 weeks (it doesn't hurt).

Long Term

Your toe will be stiffer. You might struggle with high heels or sprinting.

Q1: What is a Seymour Fracture? A: A Salter-Harris Type I or II fracture of the distal phalanx (usually in children) with an associated nail bed injury. The proximal edge of the nail plate is avulsed from the eponychial fold, creating an open fracture.

Q2: Why is "Buddy Taping" less effective for the Hallux? A: Because the 2nd toe is significantly smaller and acts as a poor splint. It cannot resist the deforming forces of the FHL/EHL tendons on the massive big toe. Rigid sole footwear is superior.

Q3: Describe the technique of "Trephination". A: Creating a hole in the nail plate to relieve pressure from a subungual hematoma. Uses a heated paperclip (cautery) or a sterile needle used in a drilling motion.

Q4: What is the risk of a displaced intra-articular fracture of the IPJ? A: Post-traumatic arthritis -> Hallux IPJ Rigidus. Painful push-off.

(End of Topic)