Immobilization and alignment
›Nonoperative management
›Buddy taping technique
›Adjacent toe as splint
›Soft padding between toes to prevent maceration
›Footwear
›Stiff-soled shoe
›Postoperative shoe
›Activity modification
›Weight bearing as tolerated
›Avoid running and jumping until pain-free
›Duration guidance
›Buddy taping typically 2 to 4 weeks for lesser toes
›First toe often longer immobilization based on symptoms
›Reduction when indicated
›Indications for closed reduction
›Visible deformity
›Angulation affecting shoe wear
›Rotational malalignment clinically
›Reduction approach
›Digital nerve block when needed
›Longitudinal traction with gentle realignment
›Post-reduction buddy taping and stiff-soled shoe
›Post-reduction verification
›Radiograph confirmation when available
›Clinical rotation reassessment
Wound care and open fracture pathway
›Open fracture management
›Irrigation and debridement planning
›Gross contamination removal
›Sterile dressing
›Antibiotic prophylaxis
›Cefazolin 2 g IV every 8 hours
›Initiate as soon as feasible
›Adjust for renal impairment when indicated
›Penicillin allergy with anaphylaxis history
›Clindamycin 600 mg IV every 8 hours
›MRSA risk consideration based on local policy
›Farm injury or heavy contamination
›Add gram-negative coverage per local protocol
›Orthopedics involvement early
›Tetanus prophylaxis
›Tdap if immunization incomplete or unknown
›Tetanus immune globulin for high-risk wounds with incomplete immunization
Nail and subungual hematoma management
›Nail complex injury
›Subungual hematoma without nail plate disruption
›Trephination for severe pain within 24 to 48 hours when appropriate
›Avoid trephination if nail plate avulsed or grossly contaminated
›Nail bed laceration with distal phalanx fracture
›Open fracture consideration
›Repair planning based on extent and clinician expertise
›Seymour-type injury pattern in pediatrics
›Distal phalanx physeal fracture with nail bed injury
›Operative irrigation and nail bed management with antibiotics pathway
Medications and symptom control
›Oral analgesics
›Acetaminophen dosing
›Adult 1000 mg PO every 6 hours as needed
›Maximum 4000 mg per 24 hours
›Ibuprofen dosing
›Adult 400 mg PO every 6 to 8 hours as needed
›Maximum 2400 mg per 24 hours
›Naproxen alternative
›Adult 500 mg PO once then 250 mg PO every 6 to 8 hours as needed
›Maximum 1250 mg per 24 hours
›Local anesthesia
›Digital nerve block
›Lidocaine 1 percent without epinephrine 3 to 5 mL total
›Bupivacaine 0.25 percent 3 to 5 mL total for longer duration option
›Medication cautions
›NSAID avoidance or caution
›Chronic kidney disease
›Active GI bleeding history
›Anticoagulant use with high bleeding risk
›Acetaminophen dose reduction consideration
›Chronic liver disease
›Heavy alcohol use
Evidence and recommendation framing
›Practice standards summary
›Closed nondisplaced lesser toe fractures
›Buddy taping and rigid-sole shoe standard
›Routine surgery not indicated
›First toe fractures
›Lower threshold for specialist follow-up
›Intra-articular displacement increases stiffness risk
›Evidence grading note
›Most recommendations based on orthopedic consensus and observational evidence
›ACEP Level A and Class I style evidence uncommon for toe fractures