Systematic Reviews
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Jun 18, 2023; 14(6): 471-484
Published online Jun 18, 2023. doi: 10.5312/wjo.v14.i6.471
Return to sport following toe phalanx fractures: A systematic review
Greg A J Robertson, Amit Sinha, Thomas Hodkinson, Togay Koç
Greg A J Robertson, Department of Orthopaedic Surgery, Queen Alexandra Hospital, Portsmouth PO6 3LY, United Kingdom
Amit Sinha, Department of Trauma and Orthopaedic Surgery, Wales Deanery, Cardiff CF15 7QQ, United Kingdom
Thomas Hodkinson, Department of Orthopaedic Surgery, Hull University Teaching Hospitals NHS Trust, Hull HU3 2JZ, United Kingdom
Togay Koç, Department of Trauma and Orthopaedic Surgery, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
Author contributions: Robertson GAJ conceived the methodology for the manuscript, performed the literature search and analysis for the study and wrote the manuscript; Sinha A performed the literature search and analysis for the study, and reviewed and edited the manuscript; Hodkinson T advised on the study, and reviewed and edited the manuscript; Koç T advised on the study, and reviewed and edited the manuscript.
Conflict-of-interest statement: All the authors declare that they have no conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Greg A J Robertson, BSc, FRCS (Ed), MBChB, MSc, PhD, Surgeon, Department of Orthopaedic Surgery, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, United Kingdom. greg_robertson@live.co.uk
Received: January 15, 2023
Peer-review started: January 15, 2023
First decision: February 21, 2023
Revised: March 19, 2023
Accepted: May 6, 2023
Article in press: May 6, 2023
Published online: June 18, 2023
Processing time: 154 Days and 10 Hours
Abstract
BACKGROUND

Evidence-based guidance on return to sport following toe phalanx fractures is limited.

AIM

To systemically review all studies recording return to sport following toe phalanx fractures (both acute fractures and stress fractures), and to collate information on return rates to sport (RRS) and mean return times (RTS) to the sport.

METHODS

A systematic search of PubMed, MEDLINE, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, and Google Scholar was performed in December 2022 using the keywords ‘Toe’, ‘Phalanx’, ‘Fracture’, ‘injury’, ‘athletes’, ‘sports’, ‘non-operative’, ‘conservative’, ‘operative’, ‘return to sport’. All studies which recorded RRS and RTS following toe phalanx fractures were included.

RESULTS

Thirteen studies were included: one retrospective cohort study and twelve case series. Seven studies reported on acute fractures. Six studies reported on stress fractures. For the acute fractures (n = 156), 63 were treated with primary conservative management (PCM), 6 with primary surgical management (PSM) (all displaced intra-articular (physeal) fractures of the great toe base of the proximal phalanx), 1 with secondary surgical management (SSM) and 87 did not specify treatment modality. For the stress fractures (n = 26), 23 were treated with PCM, 3 with PSM, and 6 with SSM. For acute fractures, RRS with PCM ranged from 0 to 100%, and RTS with PCM ranged from 1.2 to 24 wk. For acute fractures, RRS with PSM were all 100%, and RTS with PSM ranged from 12 to 24 wk. One case of an undisplaced intra-articular (physeal) fracture treated conservatively required conversion to SSM on refracture with a return to sport. For stress fractures, RRS with PCM ranged from 0% to 100%, and RTS with PCM ranged from 5 to 10 wk. For stress fractures, RRS with PSM were all 100%, and RTS with surgical management ranged from 10 to 16 wk. Six cases of conservatively-managed stress fractures required conversion to SSM. Two of these cases were associated with a prolonged delay to diagnosis (1 year, 2 years) and four cases with an underlying deformity [hallux valgus (n = 3), claw toe (n = 1)]. All six cases returned to the sport after SSM.

CONCLUSION

The majority of sport-related toe phalanx fractures (acute and stress) are managed conservatively with overall satisfactory RRS and RTS. For acute fractures, surgical management is indicated for displaced, intra-articular (physeal) fractures, which offers satisfactory RRS and RTS. For stress fractures, surgical management is indicated for cases with delayed diagnosis and established non-union at presentation, or with significant underlying deformity: both can expect satisfactory RRS and RTS.

Keywords: Acute; Stress; Fracture; Toe; Phalanx; Return; Sport; Rate; Time

Core Tip: We performed a systematic review, assessing studies that recorded return rates (RRS) and return times (RTS) to sports following acute and stress fractures of the toe phalanges. Thirteen studies were included. Seven studies reported on acute fractures (n = 156); six studies on stress fractures (n = 26). For acute fractures, 63 underwent primary conservative management (PCM), 6 primary surgical management (PSM), and 1 sary surgical management (SSM). For stress fractures, 23 underwent PCM, 3 PSM, and 6 SSM. For acute fractures, PCM conferred acceptable RRS and RTS. PSM was indicated for displaced intra-articular proximal phalanx fractures. For stress fractures, PCM, when successful, conferred acceptable RTS. Significant delays to diagnosis or associated deformity often necessitated the conversion to SSM: this was invariably successful at returning athletes to sport.