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Hallux Proximal Phalanx Fracture in Adults: an Overlooked Diagnosis Fratura Da Falange Proximal Do Hálux Em Adultos: Um Diagnóstico Esquecido

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Hallux Proximal Phalanx Fracture in Adults: an Overlooked Diagnosis Fratura Da Falange Proximal Do Hálux Em Adultos: Um Diagnóstico Esquecido DOI: http://dx.doi.org/10.1590/1413-785220202806236612 REVIEW ARTICLE HALLUX PROXIMAL PHALANX FRACTURE IN ADULTS: AN OVERLOOKED DIAGNOSIS FRATURA DA FALANGE PROXIMAL DO HÁLUX EM ADULTOS: UM DIAGNÓSTICO ESQUECIDO Alexandre Leme Godoy-Santos1 , Vincenzo Giordano2 , Cesar de Cesar Netto3 , Rafael Barban Sposeto1 , Rogério Carneiro Bitar4 , André Wajnsztejn5 , Marcos Hideyo Sakaki1 , Túlio Diniz Fernandes1 1. Lab. Prof Mario Manlio Marco Napoli, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR. 2. Hospital Municipal Miguel Couto, Prof. Nova Monteiro Service of Orthopedics and Traumatology, Rio de Janeiro, RJ, Brazil. 3. University of Iowa, Department of Orthopedics and Rehabilitation, Iowa City, IA, USA 4. Hospital das Clínicas, Ribeirão Preto Medical School, Department of Orthopedics and Anesthesiology, Ribeirão Preto, SP, Brazil. 5. Hospital Israelita Albert Einstein, São Paulo, SP, Brazil. ABSTRACT RESUMO Objectives: To describe the surgical treatment of fractures that Objetivos: destacar o tratamento cirúrgico das fraturas que envol- involves the hallux interphalangeal joint, current indications and vem a articulação interfalangiana do hálux, suas indicações atuais management options. Methods: we performed a literature review of e as opções de tratamento. Métodos: Realizamos uma revisão da literatura de estudos clínicos relevantes em múltiplas bases de relevant clinical studies in multiple databases, including PubMed, dados, incluindo PubMed, MedLine e Scopus, de janeiro de 1989 MedLine and Scopus, from January 1989 to October 2020. a outubro de 2020. Resultados: Há consenso para o tratamento Results: There is consensus for surgical treatment of intra-articular cirúrgico de fraturas intra-articulares com desvio superior a fractures with a deviation greater than 2 mm, metadiaphyseal 2 mm, fraturas metadiafisárias com má rotação e/ou malangula- fractures with malrotation and/or malangulation, open fractures ção, fraturas expostas e fraturas instáveis. Conclusão: O uso de and unstable fractures. Conclusion: The use of more rigid implants implantes mais rígidos permite a manutenção do alinhamento durante o processo de consolidação e menor risco de perda da allow alignment maintenance during healing process and lower redução. As complicações que devem ser evitadas são a defor- risk of reduction loss. Valgus deformity and interphalangeal joint midade em valgo e a osteoartrite da articulação interfalangeana. osteoarthritis are possible complications that must be avoided. Nível de Evidência III, Revisão sistemática de Estudos de Level of Evidence III, Systematic review of Level III studies. Nível III. Keywords: Hallux. Fracture Fixation. Treatment Outcome. Descritores: Hallux. Fixação de Fratura. Resultado do Tratamento. Citation: Godoy-Santos AL, Giordano V, Cesar Netto C, Sposeto RB, Bitar RC, Wajnsztejn A, Sakaki MH, Fernandes TD. Hallux proximal phalanx fracture in adults: and overlooked diagnosis. Acta Ortop Bras. [online]. 2020;28(6):318-322. Available from URL: http://www.scielo.br/aob. INTRODUCTION valgus deformity, decreased range of motion and interphalangeal 8-10 Phalanx fractures of the toes are common.1 Hallux phalanx fractures joint (IPJ) osteoarthritis can lead to significant functional loss. represent the largest proportion of all toes phalanx fractures.2 The objective of our review is to describe the surgical treatment However, hallux proximal phalanx fracture in adults has rarely of fractures that involve the hallux interphalangeal joint, current been reported.3-6 Fractures of the hallux require surgical treat- indications and management options. ment much more often than other toe fractures due to the role of the first toe in weight bearing, balance, and pedal motion.7 MATERIALS AND METHODS Diaphyseal and articular fractures of the hallux proximal phalanx We searched for relevant scientific literature from 1992 to 2019 in tend to consolidate in a good position with an appropriate initial Electronic databases, such as PubMed, MedLine and Scopus. treatment. When the principles of treatment for diaphyseal and The keywords used are shown in Table 1. intra-articular fractures are not respected, complications such as All authors declare no potential conflict of interest related to this article. The study was conducted at Laboratório Prof. Manlio Mario Marco Napoli, Departamento de Ortopedia e Traumatologia, Hospital das Clinicas, Medical School, Universidade de São Paulo. Correspondence: Alexandre Leme Godoy-Santos. Rua Dr. Ovídio Pires de Campos, 333, Cerqueira César, São Paulo, SP, Brazil, 05403010. [email protected] Article received on 16/04/2020, approved on 29/04/2020. 318 Acta Ortop Bras. 2020;28(6):318-322 Table 1. Keywords used to search the PUBMED, MedLine and Scopus Classification System database. The AO Foundation/Orthopaedic Trauma Association (AO/OTA) clas- Keywords for main PUBMED, MedLine and Scopus literature search sification updated in 2018 is the most useful classification system. Hallux Trauma Phalanx This coding system is well established, allowing a universal language 24 Incidence Fracture Adults standardization. In this system, the bone location should be deter- Prevalence Fixation Great toe mined first and the foot designation is 8. Then in the subdivisions, phalanx fractures are designated as 88. Toe identifiers are numerically Subheadings used for PUBMED, MedLine and Scopus literature search determined as hallux:1, second toe:2, etc. The bone segments are Complications Lag screw Radiology numbered as proximal end segment = 1, diaphyseal segment = 2, and Outcome Interphalangeal joint Sports distal end segment = 3.25 The universal modifiers are descriptive terms Plate Diagnosis Foot of fracture morphology, displacement, associated injury, or location that K-wire Trauma mechanism Injuries are common to most fractures (Figure 1). They are generically divided in morphology of the diaphyseal fracture and morphology for the end 25 We included case-control studies, cohort studies, epidemio- segment fractures using letters (A, B, or C). As an example, great logical studies, and case reports, written in or translated into toe, proximal phalanx, distal end segment, partial articular fracture is 24 English, which described hallux phalanx fractures, treatment classified as AO/OTA type 8811.3.B. and complications. Any available reports of hallux phalanx fractures we considered Phalan eligible. Studies that did not focus on this subject were excluded. Bone Foot phalan 88 The studies selected were read by the authors and judged Toe identiiers on their contribution to the body of knowledge of this topic. 2 The conduct and validity of any clinical studies was carefully 1 3 4 considered, and the outcomes of management protocols were one carefully scrutinized. Distal segment Diaphyseal 5 Other relevant case reports mentioning a specific association location 3 Proximal 2 Phalange with the condition were also included. Only papers that made 1 identiiers a significant contribution to the understanding of this condition were included in the review. In total, 49 abstracts were selected, 31 of which were directly related to the hallux phalanx fractures. ∙ The toes and phalanges are identiied as ollows Toes First or great toe second toe third toe Epidemiology ourth toe and ith toe Understanding the epidemiology of fractures seems to be a chal- Phalanges Proximal phalanx middle phalanx and distal phalanx lenge since the classic paper from Buhr et al.11 ∙ The toe identiier plus phalanx identiier are added etween dots Epidemiological data on the foot and ankle injuries were obtained ater the one code by authors who studied trauma-mechanism or site-specific ∙ xample Great toe middle phalanx racture is epidemiology,12,13 and others who examined population- ∙ The phalangeal one segment location is then added ∙ natomical region boneoePhalanBone segment location ype specific epidemiology.14-19 ∙ xample Great toe middle phalanx proximal end segment is An epidemiological study showed that 92.74% of all foot fractures were not work-related, 53.49% occurred outdoors and 26.12% Figure 1. AO Foundation/Orthopaedic Trauma Association coding occurred at patient’s household.1 classification system forefoot. Source: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/foot-phalanges. Shibuya et al.1 use the National Trauma Data Bank set from 2007 to 2011 to analyze the frequency and proportion of each fracture in the foot and ankle in major trauma hospitals in the United States. Trauma mechanism The authors found 280,933 foot and ankle fractures. Of those, A knowledge of the trauma mechanism is useful in understanding 15,432 were phalanx fractures, which represent 5.49% of all foot both the classification and the appropriate treatment. The three most and ankle fractures. Although metatarsal fractures were more common trauma mechanism patterns are twisting of the forefoot, common than phalangeal fractures, this study showed that the axial trauma, and crushing. The forces producing these injuries proportion of phalangeal open fractures was significantly higher are either direct (crush) or indirect (twist and axial). Specifically in than that of metatarsal fractures (33% and 16%, respectively). hallux phalanx fractures, the two mechanisms commonly involved Moreover, approximately 20% of all phalanx fractures were open.1 are axial trauma and crushing.4 In a study conducted in the United Kingdom, the authors observed Hallux fractures
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