What is it with broken toes?

[liv2ski]

I've seen one doc who says I need immediate surgery and he can get me in Tuesday. He looked at x-ray only and says the broken end has no blood supply and is dying.

WTF? How can the broken part have no blood supply? It would seem the veins are in the fleshy part, not the broken bone. 2nd opinion for sure.

[rod9301]

Don't fuck with it. Seems that an operation is the safest thing you can do. No downside, and it's a sure thing.

And it's possible that the broken bone is impinging on blood vessels.

I hurt my big toe climbing, didn't do anything about it, and now i can't climb anymore.

Toes are really important.

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[mcski]

How would he know anything about blood supply from just an X-ray? That’s a huge red flag of bs imo unless some other detail is left out. 2nd opinion for sure.

[LongShortLong]

Don't fuck with it. Seems that an operation is the safest thing you can do. No downside, and it's a sure thing.

And it's possible that the broken bone is impinging on blood vessels.

I hurt my big toe climbing, didn't do anything about it, and now i can't climb anymore.

Toes are really important.

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Thanks. I agree. Hope your toe can be fixed. From experience, it sucks to lose an activity.

[LongShortLong]

How would he know anything about blood supply from just an X-ray? That’s a huge red flag of bs imo unless some other detail is left out. 2nd opinion for sure.

Yeah, right? I messaged last night asking for more detail. I could not get in anywhere, and he made an appointment for me, and worked to get me the earliest surgery opening (that I decided to let go after 2nd doc). Doc 2 agreed surgery was reasonable, mainly because they put a pin down the middle, stabilizing the injury.

Morning after injury I had no patience. Thank dog for family members calling around for me or I might have no care - Urgent Care told me to get seen in the AM. Their HMO/network delayed half day then scheduled in July

Got the stress shits, probably from injury, but worrying over care not helping either. Intestines seem to be unknotting now. When I was a teen, I was seen for a broken finger in hours, though they decided not to align it, and it's caused minor pain intermittently ever since. Expected the same speed of care this time... with an aligned, stable, splinted toe.

I have this crazy idea to 3d-model my left foot, mirror it, and 3d-print a shell to immobilize the right foot and stabilize the toe nice and straight. Also will hold the bunion toe off of it while it heals. And provide relatively hard shell protection.

[mcski]

Hell, might consider doing the bunion at the same time ?

[MagnificentUnicorn]

Don't fuck with it. Seems that an operation is the safest thing you can do. No downside, and it's a sure thing.

And it's possible that the broken bone is impinging on blood vessels.

I hurt my big toe climbing, didn't do anything about it, and now i can't climb anymore.

Toes are really important.

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Yeah because a hallux fracture and a distal phalanx fracture of the second toe are the same thing. No downside to surgery? How about infection, non/mal-union and possibly arthritis? Do you have any clue how small the distal phalanx in the second toe is? I’ve worked in surgery for almost 36 years and I don’t remember ever seeing an ORIF of a distal phalanx except for the hallux/great toe.


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[LongShortLong]

Yeah because a hallux fracture and a distal phalanx fracture of the second toe are the same thing. No downside to surgery? How about infection, non/mal-union and possibly arthritis? Do you have any clue how small the distal phalanx in the second toe is? I’ve worked in surgery for almost 36 years and I don’t remember ever seeing an ORIF of a distal phalanx except for the hallux/great toe.


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Oops, did I write distal? My break is the proximal phalanx bone, adjacent to meta-tarsal (aka arch). The break is near the distal end of that bone. I also wondered about the size of the bones and how well a surgeon could align small slippery things. And whether it would be aligned just as well externally. Though a pin would give me much confidence it would stay aligned while healing.

Do you see ORIFs of proximal #2 with no joint involvement?



The other two images did not show misalignment according to doc 2, but who knows how it's moved since then. After buddying to the big toe, it had 20 degrees or so bend (via eyeball). I buddied to toe#3, and it looks straight to me now (no pain, no force to realign). No idea how it looks now in other image planes. In my experience adjusting it the first day, it only moved in the one plane, though I felt it would move elsewise if I tried. First time I thought maybe it was just dislocated, but alas it's broken.

There doesn't seem to be much pain. Maybe my back pain dominates it, though I think it's not much pain. Occasionally there is some dull pain or burning sensation.

[LongShortLong]

Hell, might consider doing the bunion at the same time ?

Doc 2 suggested that if I opt for surgery. Doc 2 also thought it fine to do surgery after healing though who wants to recover twice?

My thinking is if it heals straight or at least really functional, then I can put off the bunion surgery a few more decades.

[LongShortLong]

How it looks without the surgical shoe. MacGyver'ed it

Big toe held to side with long skewer, countering a few degrees of bunion. #2 sistered to #3, with a folded up paper on the joint so it pivots straight. Twist-tie pulls pair just a bit to the left - I don't want #2 having any ideas about stretching longer as it heals. Also want it to continue supporting the bunion post recovery. That pair is raised, dunno if I should force them down to touch the shoe. The piece of paper on #2 and 3 hold the skewer segment off the skin. Short skewer is mainly insurance against bumps (until I added twist-tie).

Here's someone else's 3d printed cast. I was thinking to cover the whole forefoot, with a top shell and bottom shell clamshelled together. With added craft work as needed to align #2 before taping the clam shut. Then I can ditch the tape, bamboo, and twist-tie.

[old goat]

It's tough when you have a second opinion that disagrees with the first. At that point I would tend to go with the doc who gives the explanation that makes the most sense. You mentioned concern about the blood supply to the distal fragment. Then the question would be--how do you know that. And let him explain the blood supply to the toe bones, To the guy who says buddy taping is enough--will I be functionally impaired if it doesn't heal or heals crooked. Make them make sense to you.

[MagnificentUnicorn]

Oops, did I write distal? My break is the proximal phalanx bone, adjacent to meta-tarsal (aka arch). The break is near the distal end of that bone. I also wondered about the size of the bones and how well a surgeon could align small slippery things. And whether it would be aligned just as well externally. Though a pin would give me much confidence it would stay aligned while healing.

Do you see ORIFs of proximal #2 with no joint involvement?



The other two images did not show misalignment according to doc 2, but who knows how it's moved since then. After buddying to the big toe, it had 20 degrees or so bend (via eyeball). I buddied to toe#3, and it looks straight to me now (no pain, no force to realign). No idea how it looks now in other image planes. In my experience adjusting it the first day, it only moved in the one plane, though I felt it would move elsewise if I tried. First time I thought maybe it was just dislocated, but alas it's broken.

There doesn't seem to be much pain. Maybe my back pain dominates it, though I think it's not much pain. Occasionally there is some dull pain or burning sensation.

My bad, you did say proximal. However that’s a really small piece of bone on the X-ray and you probably fuck it up more trying to pin it or open it and put screws in. If you have surgery the recovery would likely be the same as conservative treatment. You’re going to be in a cast boot or post op shoe with non weight bearing. It’s in the joint so I would bet it’s going to wind up stiff either way. Phalanges, fingers or toes rarely heal without stiffness if the joint is involved. I would try conservative treatment if it was me but everyone needs to decide about surgery on their own.

I was mostly responding to rod’s claim that there’s no downside to surgery.


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[LongShortLong]

It's tough when you have a second opinion that disagrees with the first. At that point I would tend to go with the doc who gives the explanation that makes the most sense. You mentioned concern about the blood supply to the distal fragment. Then the question would be--how do you know that. And let him explain the blood supply to the toe bones, To the guy who says buddy taping is enough--will I be functionally impaired if it doesn't heal or heals crooked. Make them make sense to you.

Agree. Doc 1 seems to have the minority opinion. I asked for further explanation, but none came - maybe his office wanted to bill another appointment to get the answer, but idk, it's Saturday. Doc 2 says surgery ok, and waiting ok, and surgery later ok if there's problems. Also to see doc 3, a surgeon. In the appointment, she seemed to support the surgery option, but I got her to call back for clarification, and my read is she supports buddy taping, but wasn't advising against doc 1's surgery though she did disagree about the blood supply issue. She also examined me, and my sister was there to ask more questions, so it was a more productive visit overall for me. Especially appreciated the call back.

[LongShortLong]

My bad, you did say proximal. However that’s a really small piece of bone on the X-ray and you probably fuck it up more trying to pin it or open it and put screws in. If you have surgery the recovery would likely be the same as conservative treatment. You’re going to be in a cast boot or post op shoe with non weight bearing. It’s in the joint so I would bet it’s going to wind up stiff either way. Phalanges, fingers or toes rarely heal without stiffness if the joint is involved. I would try conservative treatment if it was me but everyone needs to decide about surgery on their own.

I was mostly responding to rod’s claim that there’s no downside to surgery.


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Thanks. I don't want to hear about stiffness, but good to know it's waiting for me with either approach. I also appreciated Rod's surgery plug, and my limited reading says it's more often warranted on the big toe. Likewise liv2ski's comment about a curved toe that works fine.

I'm leaning hard toward conservative treatment, especially if I can 3d print something that makes it easy. My MacGyver taping satisfies me alignment and immobilization-wise, but it is a pain in the ass, and I'm concerned that movement during untaping/retaping it will impede healing. And that applies to any buddy taping. In doc 2's office visit, it looked like the tape is causing skin irritation. And those problems apply to any buddy taping, the others just trade simpler taping for less alignment and stability. Maybe I can leave the current setup on for two weeks or however long before the toe needs less support.

[MakersTeleMark]

I broke the same foot 2x this year on opposite sides. FML. I'm getting really good at reeling back and healing quickly, but it is really tough.

[timackie]

So, interweb health care advice is tricky. Lots of unknowns. And there are different practice patterns in different parts of the US. And if you are in Canada, things get even more variable, eh? And how do you know that anybody's advice is sound?

But if you are a healthy, active, non smoker, most (all?) of the foot and ankle docs I have worked with in Denver would advise surgery for your injury. Their advice would focus on 3 topics. You mentioned concerns for blood supply. I think this is a rare complication of this fracture that may be decreased with surgery. But it is a rare complication that would likely cause significant arthritis that could be treated with a fusion of that joint in the future if needed.

The biggest concern about this fracture is that it is intra articular/ broken joint surface. I was a bicycle mechanic in a previous life and I describe the joint surfaces like the cups and cones of the old wheel hub. If things aren't smooth, it will wear out early. AKA arthritis. The intention of the surgery is to align the joint surfaces as best as able. Even a 1-2 mm irregularity in the joint surface increases the risks for arthritis. Perhaps earlier and more severe as well. But keep in mind that the injury has already predisposed the joint to arthritis, so surgery is no guarantee of a pain free toe. There is no sure bet, but if it becomes chronically painful, the involved joint could be fused in the future.

Another intention of surgery is to avoid deformity. When we get even older than we already are, plenty of us loose protective sensation in our feet and a deformed toe can cause wounds on the feet that cause infections and potential amputations.

So my advice is to seek another opinion, maybe a few, and keep going until you have met a doc that you feel comfortable with and trust. If surgery is elected, any time within the first 2 weeks or so after the injury should not complicate the surgical repair.

Lastly, that MacGievered thing on your foot is gonna tear your skin off. I prefer Coban or vet tape to that sticky stuff as it sticks to itself, not your skin. Maybe tape the big toe to the long toe and use the post op shoe and loose the outrigger? But you do you.

I hope that this is more helpful than confusing and best of luck with a rapid recovery.

[MagnificentUnicorn]

^^the last paragraph is good advice. If you can find 1” coban or even 1/2” I’d buddy wrap the 1st and 2nd toes. Maybe put a bolster like a dental roll between the toes for alignment and WEAR the post op shoe.


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[jerlane]

Lots of medical advice here from non-medical professionals, but I guess that’s the TGR way!

Yes, the blood supply to the bone is within the bone and can be disrupted with certain fractures. Loss of vascularity (leading to non-union, or AVN)can be a risk with certain fractures ie Jones fracture of the fifth metatarsal or scaphoid.
I don’t think that is a big risk for this fracture. The bigger concern is the degree of instability. Will the fracture stay put long enough to heal? If it keeps displacing the way you described it initially is a bit concerning. I’m definitely impressed with your Franken-splint!


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[LongShortLong]

I broke the same foot 2x this year on opposite sides. FML. I'm getting really good at reeling back and healing quickly, but it is really tough.

Hope you are better quickly, and I'll try not to do that.

Hey folks - protect your toes. I may reconsider going shoeless at home.

[LongShortLong]

So, interweb health care advice is tricky. Lots of unknowns. And there are different practice patterns in different parts of the US. And if you are in Canada, things get even more variable, eh? And how do you know that anybody's advice is sound?

But if you are a healthy, active, non smoker, most (all?) of the foot and ankle docs I have worked with in Denver would advise surgery for your injury. Their advice would focus on 3 topics. You mentioned concerns for blood supply. I think this is a rare complication of this fracture that may be decreased with surgery. But it is a rare complication that would likely cause significant arthritis that could be treated with a fusion of that joint in the future if needed.

The biggest concern about this fracture is that it is intra articular/ broken joint surface. I was a bicycle mechanic in a previous life and I describe the joint surfaces like the cups and cones of the old wheel hub. If things aren't smooth, it will wear out early. AKA arthritis. The intention of the surgery is to align the joint surfaces as best as able. Even a 1-2 mm irregularity in the joint surface increases the risks for arthritis. Perhaps earlier and more severe as well. But keep in mind that the injury has already predisposed the joint to arthritis, so surgery is no guarantee of a pain free toe. There is no sure bet, but if it becomes chronically painful, the involved joint could be fused in the future.

Another intention of surgery is to avoid deformity. When we get even older than we already are, plenty of us loose protective sensation in our feet and a deformed toe can cause wounds on the feet that cause infections and potential amputations.

So my advice is to seek another opinion, maybe a few, and keep going until you have met a doc that you feel comfortable with and trust. If surgery is elected, any time within the first 2 weeks or so after the injury should not complicate the surgical repair.

Lastly, that MacGievered thing on your foot is gonna tear your skin off. I prefer Coban or vet tape to that sticky stuff as it sticks to itself, not your skin. Maybe tape the big toe to the long toe and use the post op shoe and loose the outrigger? But you do you.

I hope that this is more helpful than confusing and best of luck with a rapid recovery.

I trust nothing on the internet and wish it were easier to talk to real docs. Thanks for your insights. No one in real life has mentioned joint involvement, but two of you dentists see it so far. I'll ask at my appt.

Doc 2 taped the long toe #2 to the big toe. I retaped because that made a 20 degrees bend to the right. Taping to #3 makes it almost straight and a small rolled up paper wedge near the joint pivoted it about perfect. I have better tape for the next time. Not looking forward to peeling it off. Was hoping I'd have a 3d-printed splint by about now, or soon, but that's harder to materialize than I thought. My goal with a 3d-splint is no or minimal tape on skin, and easy access to inspect and re-splint. And less MacGyver.

Doing my best to baby this toe, and care for a chronic back that requires some movement. Post-op shoe is on 24-7 unless I'm checking toes or adjusting the splint. Big toe didn't like the skewer pressing on the nail so I bolstered it. Etc. Lying supine with about foot elevated, in a 3-sided box to keep ankle near 90 degrees. I crawl, crabwalk, or use crutches to move.

[LongShortLong]

Lots of medical advice here from non-medical professionals, but I guess that’s the TGR way!

Yes, the blood supply to the bone is within the bone and can be disrupted with certain fractures. Loss of vascularity (leading to non-union, or AVN)can be a risk with certain fractures ie Jones fracture of the fifth metatarsal or scaphoid.
I don’t think that is a big risk for this fracture. The bigger concern is the degree of instability. Will the fracture stay put long enough to heal? If it keeps displacing the way you described it initially is a bit concerning. I’m definitely impressed with your Franken-splint!


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Given the toe was flopped over 45 degrees, Imma guess any internal blood supply was severed. Dunno if that's the same as disrupted - the parts are together again now, and I think the splint is good, meaning two days of minimal motions, besides jarring the shoe and muscle twitches. I also habitually tense the top tendons on my foot.

I also think the prior buddy splint was reasonably good the two prior days. At the appointment, we carefully untaped it (doc let me do it). Then she buddy taped to big toe which caused it to bend 15-20 degrees in the direction of the flop. When I got home, my sister and I started MacGyvering on the left foot (guinea pig!), then made the right foot splint pictured above.

It's not especially painful, and there were no pain spikes removing or adding any of the splints so far. Dunno if that's good or bad. I'd guess the initial and repeated 45 degree flops mean the distal bone fragment of the fracture likely lost its nerves too, but the rest of the injury ought to be innervated (plugged in and sending pain). Those eventually grow back I hope. The toe tip has sensation and is as warm/pink as the others. The most recent 45 degrees flop was leaving x-ray 2 hours post-injury.

Thanks for the splint compliment.

[Talisman]

The only advice I can add is do not ride the subway while your toe is healing. I had two broken toes on the mend and after two weeks a large person stepped on my foot when the subway car lurched. Back to square one with the toes.

[LongShortLong]

Lesson - take broken bones to the ER.

Saw another private DPM. And got fresh xrays that look about the same. Fracture is offset as in first xray, there's a small lean to the right, and a small right-hand twist.Doc says injury should have been properly reduced in first 24 hours, but now it's straight enough that he recommends no treatment. (Also says ER docs are much better at trauma than UC docs.) Will function the same under any treatment now, with same pain outcome (some arthritis risk). Arthritis depends whether the healing process affected the joint. If I want it straighter now, he would numb and pull it, or ORIF it. I care about function, so no treatment it is.

Says X-ray does indicate for surgery, even now, but clinical does not - looks pretty straight. Rx Minimal activity. Keep babying it four more weeks. Keep the surgishoe on 24-7. Don't reinjure.

And curse managed healthcare for caring more about following process than timely treatment. Fuckers dallied and led me on the first morning, and have cancelled several appointments, sometimes without notice. Bureaucratic bunglers. "Oh that opening didn't really exist, should not have been scheduled" Or we cancelled that bc "you can only have one DPM" never mind the referral from the first to second. Feels like they're gaslighting me, but maybe they just bungle a lot, make promises that someone else breaks.

[bodywhomper]

Did they rec PT once you can get out of the shoe and flex the foot? I broke pinky several years ago. 10 wks with foot immobilized. Once for the thumbs up to begin regular activity, the doc didn’t mention pt. I went about regular athletic and life stuff. Come winter, I started having upstream problems (knee). Saw a physiatrist who dx’ed issues from leg atrophy from the immobilization 9 months prior. It was visually noticeable once pointed out to me. PT set me straight.

[raisingarizona13]

It's the farthest extremity from your core and there's is barely any tissue around that bone so they can be real slow to heal not to mention they are real easy to continue to re-injure during the process. I swear it's like a broken tow is a magnet for table and chair legs. At 48 years old I don't expect any broken bones to be put on the fast track for healing. The body just doesn't do that anymore.