Chapter 14 411

Phalanges of the Foot

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

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. Fig.14.1
Age of appearance of secondary centers of ossification
of foot phalanges. m months
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 sification center and do not form a separate SCO [11].
ther end. The great toe almost always has two phalan The middle phalange of the 5th toe does not develop
ges, each with one SCO proximally. The second, third, an ossified epiphysis at either end in 95% of individu
and fourth toes, however, usually have three phalan als [2].
ges and rarely two, while the fifth toe has three or Secondary centers of ossification appear roentgen
two phalanges in nearly equal frequency. There may ographically at different times in each phalanx in
be no SCO for the middle phalanx of the third, fourth, each toe (Fig.14.1). In the great toe the distal phalanx
and fifth toes, and for the terminal phalanx of toes SCO appears first between 8 and 21months, and the
with two phalanges [2, 11, 15, 16]. These phalanges proximal phalanx later, between 15 and 36months.
grow from the physis at each end of the primary os In the lateral four toes the opposite is true; the SCO of
412 Chapter 14
the proximal phalanges appear first, between 9 and
36months, and of the distal phalanges between 24
and 36months. 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 416years [14]. They occur
Phalanges of the Foot
Fig.14.2
Normal cone shaped phalanges in a 6year 2month 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 13years
0months all physes are closed and all phalanges are
normal
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 type4 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.
 Phalanges of the Foot Chapter 14 413

Fig.14.3
Sagittal cleft epiphysis, proximal phalanx right great toe in a 11year 7month old boy. There was no history of injury
and physical examination was normal. a The cleft (arrow) at age 11years 7months. b The cleft was still present at age
13years 3months. 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 10year 11month old boy
414 Chapter 14
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, type3 frac-
ture
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 type2
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 of the Foot
phalanges. In girls the closure rate is 5% at age 11years,
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 13years (Fig.19.5d), 20% at age 14, and 35%
by age 15years [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 (Table4.5) [8]. Fifty-seven frac
tures reported between 1970-1990 accounted for 5%
of all physeal fractures (Table4.6) [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 type2 [3, 6, 12] or type3
[10] fracture. The metaphyseal fragment of type2
fractures is usually small. The largest series is 6 cases
[10] (4 boys 2 girls, ages 714years, all barefoot at time
of injury, and all type3 fractures).
Olmsted County Study
Toe phalanges ranked sixth in overall frequency ac
counting for 6% of all physeal fractures (Table4.12)
[9]. There were 55 fractures in 37 males and 18
females. The ages in boys ranged from 5 through
17years (peak age 10years), and in girls from 6
through 15years (peak age 10years). There were 7
type1, 30 type2, 6 type3, 8 type4, 4 type5, and
no type6. It is suspected that had types1 and 6
been identified and documented prior to the study
that the numbers would have been greater, particu
larly type1.
 Phalanges of the Foot
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
514days 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]. Type1 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 well-aligned and well-healed fracture in 3
4weeks (Figs.14.6c, 14.7b). A hard-soled shoe with
the dorsum of the toe portion removed is sufficient
for weightbearing.
Fractures that would benefit from reduction are
those with intra-articular displacement (types4 and
5) involving more than 25% of the articular surface,
those with more than 2mm 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]. Type5 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
Chapter 14 415
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
ble8.1) [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 in-patient 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.
416 Chapter 14 Phalanges of the Foot

Fig. 14.6
 Phalanges of the Foot Chapter 14 417

Fig.14.6
Fourth toe proximal phalanx type1 fracture. This 11year 1month 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 11days. 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 type1 frac-
ture, in a 14year 5month old boy. .
a Type1 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 type2 fracture.
The great and second toes were taped
together for 7days. b Four weeks .
later, transmetaphyseal sclerosis (ar-
rows) confirms compression component
of the type1 fracture

Fig.14.8
Little toe proximal phalanx type2 fracture. This 9year 3month old girl fell while doing a handstand. a Type2 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 12years 4months. The fracture was healed and the physis was closing normally
418 Chapter 14 Phalanges of the Foot

Fig.14.9
Great toe proximal phalanx type5 fracture. This 9year 0month 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 type5 fracture. Treatment consisted of a short leg walking cast supporting the toe
for four weeks. c Five years 1month later, age 14years 1month. 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

Refracture
Refracture in one case [6] may have been associated
with soft tissue interposition or nonunion.
References
1. Buch BD, Myerson MS: Salter-Harris typeIV epiphyseal
fracture of the proximal phalanx of the great toe: A case
report. Foot Ankle Int 16:216-219, 1995
2. Flecker H: The time of appearance and fusion of ossifica
tion centers as observed by roentgenographic methods.
Am J Roentgenol 47:97-159, 1942
3. Kay RM, Matthys GA: Pediatric foot fractures: Evaluation
and treatment. J Am Acad Orthop Surg 9:268-278, 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 21:31-34, 2001
5. Mizuta T, Benson WM, Foster BK, Patterson OL, Morris
LL: Statistical analysis of the incidence of physeal injuries.
J Pediatr Orthop 71:518-523, 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:122-125, 1994
7. Ogden JA. Injury of the growth mechanism of the imma
ture skeleton. Skel Radial 6:237-253, 1981
8. Peterson CA, Peterson HA: Analysis of the incidence of in
juries to the epiphyseal growth plate. J Trauma 12:275-281,
1972
9. Peterson HA, Madhok R, Benson JT, Ilstrup DM, Melton
III LJ: Physeal fractures: Part 1. Epidemiology in Olmsted
County, Minnesota, 1979-1988. J Pediatr Orthop 14:423-
430, 1994
 Phalanges of the Foot
10. Pinckney LE, Currarino G, Kennedy LA: The stubbed
great toe: A cause of occult compound fracture and infec
tion. Radiology 138:375-377, 1981
11. Pyle I, Sontag LW: Variability in onset of ossification in
epiphyses and short bones of the extremities. Am J Roent
genol 49:795-798, 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:375-383, 1959
Chapter 14 419
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 19:131-136, 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 14:129-152,
1956
16. Venning P: Sib correlations with respect to the number of
phalanges on the fifth toe. Ann Eugen London 18:232-254,
1954