Rosen & Barkin's 5-Minute Emergency Medicine Consult (538 page)

• 033.0 Whooping cough due to bordetella pertussis [B. pertussis]
  
• 033.1 Whooping cough due to bordetella parapertussis [B. parapertussis]
  
• 033.9 Whooping cough, unspecified organism
  

BASICS

• The phalanges of the foot are prone to injury.
  
• 5th (or small) toe most commonly affected
  

• Usually the result of direct trauma
  
• Stubbing the toe, kicking a hard surface, or dropping a heavy object onto toes most common mechanisms of injury
  

DIAGNOSIS

History may predict the type of injury found and should include:

• Time of injury
  
• Mechanism
  
• History of previous trauma
  
• Status of tetanus immunization if laceration is present
  

• Tenderness, swelling, crepitus, and ecchymosis of affected digit
  
• Subungual hematomas are often present.
  
• Lacerations or crush-type wounds
  
• Document neurovascular status of the affected digit.
  

Radiographs of involved digit

• Radiographs of involved digit
  
• Lateral view may be most sensitive.
  

• Fracture
  
• Contusion
  
• Abrasion/laceration
  
• Dislocation
  

TREATMENT

• Ice to affected digit
  
• Direct pressure and dressing to any wounds
  

• Ice to affected digit
  
• Direct pressure and dressing to any wounds
  

• Fractures involving the proximal phalanx and interphalangeal (IP) joint of the hallux:
  
  • Nondisplaced, non–intra-articular fractures may be placed in a short-leg walking cast with toe extension for comfort.
    
  • Displaced, non–intra-articular fractures:
    
• Closed reduction with digital block anesthesia
  
• Longitudinal traction
  
• Placement in short-leg walking cast with toe extension:
  
  • Intra-articular fractures of the hallux merit orthopedic consult:
    
    • Frequently treated with open reduction and internal fixation
      
• Fractures involving the proximal phalanx and IP joint of the lesser toes:
  
  • Rarely cause long-term disability
    
• Nondisplaced fractures:
  
  • Treat with splinting or buddy taping
    
  • Gauze padding between the taped toes to prevent skin breakdown
    
• Displaced fractures:
  
  • Closed reduction by digital block anesthesia
    
  • Longitudinal traction
    
  • Buddy taping or splinting
    
  • Hard-sole shoe, weight bearing as tolerated
    
  • Oral analgesics for pain
    
  • Pain usually resolved by 2–3 wk
    
• IP joint dislocations:
  
  • Closed reduction by digital block anesthesia
    
  • Longitudinal traction with gentle downward pressure on distal phalanx
    
  • Buddy tape to adjacent toe
    
  • Unstable or unsuccessful reductions require orthopedic consultation.
    
  • Oral analgesics for pain
    
• Distal tuft fractures:
  
  • Subungual hematomas should be drained.
    
  • Nail-bed laceration repair may be necessary.
    
  • Buddy tape digit to adjacent toe.
    
  • Weight bearing as tolerated
    
  • Oral analgesics for pain
    
  • Pain usually resolved in 2–3 wk
    
• Open fractures:
  
  • Orthopedic consultation
    
  • Prophylactic antibiotics
    

• NSAIDs are useful in treating acute pain:
  
  • Ibuprofen 800 mg (peds: 5–10 mg/kg) PO TID
    
• Narcotic analgesics may be required for severe pain
  
• Consider antibiotics for open wounds
  
  • Cefazolin: 1 g IM/IV in ED (peds: 50–100 mg/kg IM/IV in ED) for open fractures
    
  • Cephalexin 500 mg PO QID (peds 25–50 mg/kg/d in div. doses) for 7 days for dirty wounds.
    

FOLLOW-UP

• Unstable or blocked dislocations
  
• Open fractures require orthopedic consultation in the ED.
  

All other fractures may be discharged with orthopedic follow-up in 2–3 wk to evaluate healing.

Patient copies of any radiographs obtained may facilitate early follow-up.

• Intra-articular fractures involving the proximal phalanx of the great toe require urgent orthopedic or foot and ankle surgery follow-up.
  
• Simple nondisplaced fractures of the small toes may often be followed by primary care physicians.
  

Open, displaced, or intra-articular fractures, particularly involving the hallux, merit orthopedic consultation.

• Ho K, Abu-Laban RB. Ankle and foot. In: Marx JA, ed.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. Philadelphia, PA: Mosby/Elsevier; 2010:670–697.
  
• Mittlmeier T, Haar P. Sesamoid and toe fractures.
  Injury
  . 2004;35(suppl 2):SB87–SB97.
  
• Schnaue-Constantouris EM, Birrer RB, Grisafi PJ, et al. Digital foot trauma: Emergency diagnosis and treatment.
  J Emerg Med
  . 2002;22:163–170.
  
• Wedmore IS, Charette J. Emergency department evaluation and treatment of ankle and foot injuries.
  Emerg Med Clin North Am
  . 2001;18:85–113.
  

CODES

• 826.0 Closed fracture of one or more phalanges of foot
  
• 924.3 Contusion of toe
  
• 959.7 Knee, leg, ankle, and foot injury
  

BASICS

• 1/3 of all traumatic injuries affect the hand.
  
• Phalanges account for 1 of the most frequently fractured parts of the skeletal system with the distal phalanx being the most commonly fractured bone in the hand.
  
• Dorsal displacement of the proximal interphalangeal joint of the finger is the most frequent dislocation.
  

Injuries may be more difficult to diagnose in children who are unable to cooperate for a full exam.

• Trauma (commonly work or sports related)
  
• Infectious sequelae:
  
  • Skin flora:
    Staphylococcus aureus
    and
    Streptococci
    
  • Cat/dog bites:
    S. aureus
    and
    Pasteurella multocida
    
  • Human bites: Eikenella
    
  • Thorns or woody plants puncture: Fungal
    
  • Fresh/salt water exposure:
    Mycobacterium marinum
    and
    Pseudomonas aeruginosa
    
• Overuse injury (e.g., “gamekeeper’s thumb”)