It's the middle of the night. You're trying to make it to the bathroom and....crack. You hit the bed post with your foot. After waking the rest of the family with your howls, you inspect the toe only to find it is rapidly turning black and blue. It's a broken toe.

The 5th or little toe is by far the most common toe that we treat for fractures.  These fractures usually occur in a spiral oblique manner meaning that the bone breaks and spirals through the proximal phalanx (see discussion of anatomy below).  Bruising occurs due to a crack in the outer cortex of the bone.  This crack leads to bleeding in an enclosed space (subcutaneous space) adjacent to the skin.  Fractures can also be the result of an impaction force or crushing force.

Principals of fracture care are similar regardless of the location of the fracture. For optimal healing, apposition and alignment of the fracture is essential. 

Treatment of a broken toe

Broken toes aren't hard to treat as long as we adhere to some of the basic principals of fracture care. First, it's a good idea to get an X-ray. Why? Well, the key to healing is to insure that the fracture is aligned and shows good apposition. Without good alignment and good apposition, the fracture will not only take longer to heal but may heal in poor alignment and be crooked. Without an x-ray, it's just a guess as to whether the alignment and apposition of the fracture fragments is correct.  An x-ray also confirms whether the fracture extends into a joint.  Fractures that extend into a joint will not only take longer to heal but may have a higher incidence of arthritis in that specific joint in years to come.

In all cases, rest, ice and elevation are important. Rest and elevation will enable the body to begin the natural process of healing. Ice is a simple way to mediate the natural inflammatory response post fracture.

One recommended method of treating a broken toe is buddy splinting.  Buddy splinting of the toes works for some patients but can be a challenge for others. We find a self adherent wrap such as 1 Co-Flex works well for splinting a single toe. As an alternative to buddy splinting, we recommend that you use Co-Flex to wrap just the injured toe.  Co-Flex is used to wrap the toe in a cylindrical manner almost like a little cast. In this way, the fracture is not only splinted but swelling is also controlled. Co-Flex can be reused so that a little strip can last several days.  Another splinting alternative is a toe straightened.  Single and double toe straighteners are often used to passively re-align poorly aligned digital fractures. And lastly, fracture shoes are also helpful to allow for ambulation while offering enough room for the fractured toe.

Some digital fractures will require surgical care.  Re-alignment of the fracture can usually be accomplished through closed reduction with or without pin fixation.  Closed reduction means that the fracture is re-aligned with the patient under anesthesia but without an open incision.  If fixation is used, pins remain in the fracture for a period of 2-6 weeks post closed reduction.

Another common problem with digital fractures is a contusion to the nail with bruising that develops beneath the nail.  This bruising is called subungual hematoma.  Pressure that builds under the nail due to subungual hematoma should be relieved as soon as possible.  A specialized nail drill is used to carefully tap the bruising found beneath the nail.  Under optimal circumstances, draining the bruise should be carried out within 24-36 hours post-injury.  Patient's notice a marked reduction in pain following this procedure.  The subungual pressure caused by subungual hematoma will often forced the nail to float away from the underlying nail bed.  Over several weeks to months, the nail will slough off and a new nail will slowly (over a year) grow back to replace the old nail.  During this time, the new nail is very susceptible to fungal infections and should be treated with a topical antifungal lotion or cream.  In a limited number of cases, the new nail may grow back to be poorly shaped and becomes ingrown.  The ingrown nail can be treated with a nail brace or by a minor surgical procedure at your local podiatrists office.

Ice, elevation and an anti-inflammatory medication will help to ease some of the pain. What's typically a surprise to most folks is how long a fractured toe can take to heal.  Fractured toes may take up to 10 weeks to heal depending upon the apposition and alignment, severity of the fracture and the patient's overall ability to heal.

Broken toe - a break in the bone that includes many varieties of fractures (see compound, comminuted).

Comminuted fracture - a fracture that consists of multiple pieces.

Compound fracture - a fracture that breaks the skin.

Cortex - the outer, hard exterior layer of bone.

Fractured toe - see broken toe.

Subungual hematoma - a bruise beneath the nail.

The bones of the toes consist of two different types of bone.  The central 80% of these bones consist of a hard material called cortical bone.  Cortical bone is very hard on the outside and difficult to break.  The ends of the bone though are very different and are made of a softer bone called cancellous bone. 

Most fractures of the toes involve one or both of these types of bone.  As mentioned earlier, most digital fractures are a spiral oblique fracture that extend the length of the bone including both cortical and cancellous bone.  Breaking the bone disrupts the normal blood supply of the bone.  The bleeding will escape through the break and create a very obvious bruise post fracture.

The mechanism of injury in a spiral oblique digital fracture is quite interesting. When the 5th toe comes in contact with the fixed object  (bedpost), the base of the proximal phalanx is held firm by the ligaments of the metatarsal phalangeal joint. Continued force is applied to the toe that separates the 5th toe from the 4th toe.  This force generates a bending type of force to the proximal phalanx.  As the bone fatigues, the bone fractures in a very predictable oblique pattern.

Most broken toes obviously have an acute onset. Symptoms of a broken toe include edema (swelling), ecchymosis (bruising) and difficulty getting into regular shoes. So how can you differentiate a broken toe from a sprain? It's not always easy without and x-ray, but as a general rule of thumb, toe injuries with significant bruising typically are fractures.

What surprises most people is that the symptoms of a broken toe may last 8-10 weeks. Although it may be a little toe, you have to remember that a toe fracture injures bone, ligaments and tendon. These structures heal no faster in a little toe than they would in a wrist, elbow or other joint. So depending upon the apposition and alignment of the fracture, your general health status and your age, fracture healing will takes weeks to become pain free.

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This article was written by Jeffrey A. Oster, DPM and last updated 9-18-09.  No additional information is available for this topic.