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Hi,
I had a patient present yesterday:

35 yo female involved in a motor vehicle accident in Dec 2011. Mulitple issues, including back related issues that resulted in surgery, and a sprained left ankle. As the back was the major concern, her right toe was not noticed until February this year, where continued soreness led her GP to X-ray:

Found a fracture at the right hallux distal phalanx (see pics). Consult with the orthopod in March whilst reviewing her back said that toe surgery would cause more trouble than what its worth - and the TAC wouldn't pay because it was too long ago now!!! (they only found the fracture in February!). However pain is still noticable, toe still swollen and mild passive flexion of IPJ produces pain, thus the visit to me. Absolutely no issue at the MPJ. WB ok, until toe off. Gait appears laregely unhibited but patient has ongoing back pain.

First off, I have shown her how to self tape (I do similar for hyperextension injuries) to minimise IPJ movement. Next step more rigorous offloading techniques to minimise IPJ movement (rocker bottom shoes, carbon fibre plates in shoe or mortons extension)

The Xray shows some obvious displacement of the distal phalanx and I guess my question is, should surgery be considered now, rather than try the conservative measures first? Obviously if the conservative measures fail, then fair enough, but I don't want to needlessly delay the inevitable.

THanks in advance,

Björn

P.S> Sorry for bad pics

 

I agree with most of your treatments. A Morton's extension can be helpful in that it creates somewhat of a rocker effect within the shoe. The Morton's extension can also limit motion of the MPJ wich could increase load on the hallux in gait. Treatments, that help 1st mpj dorsiflexion, (increased supination moment from an orthosis, reverse Morton's exttension) could decrease stress on the hallux.

The joint, on x-ray, looks pretty bad. It appears the fractue was intra articular. I would agree that you should try conservative stuff first, but the conservative is not going to make the joint better, just less painful. The decision to go to surgery should be the patient's. It really depends on how much the pain in the toe limits her. If I had pain every step, and my joint looked like that, I'd probably have surgery.

Try turning the room light off, use a tripod, and a long exposure. You can see the reflection of your phone/camera best in the middle picture. When will they make a phone with a tripod?

Eric

 

Thanks Eric for the tips. I will see how the patient presents next visit, and discuss the options. I think if it's still painful, I might suggest a surgical opinion.

The phone tripod idea could make you a wealthy man!

 

I would wait for surgery.
These traumatic arthritic IP joints of the hallux frequently go through a self arthrodesis process in which it more or less takes care of itself.

If your patient has limited ROM at the 1st MTPJ then the IPJ will be more symptomatic.

IPJ fusion is fairly simple if it comes to that.

Steve

 

Thanks Steve,

THe range at MPJ is quite reasonable. I can't remember off the top of my head, but it was above 45 degrees,