Barefoot stubbing injuries to the great toe in children: a new classification by injury mechanism.

Objective: This study was conducted to categorize barefoot stubbing injuries to the great toe in children by injury mechanism to differentiate benign stubbing injuries from more complex injuries necessitating surgery.
Design: Prospective clinical series of consecutively treated patients.
Setting: Tertiary university hospital setting.
Patients: Forty-one children who had sustained an indirect injury to the great toe during barefoot sports activities between January 2001 and December 2009 were included.
Intervention: Conservative or surgical treatment was done according to clinical and radiological findings.
Main Outcome Measurement: Information regarding injury mechanism was collected from patients, parents, and coaches using skeletal models and assessed by a pediatric orthopedic surgeon. Mechanisms of injury were identified and grouped as follows: hyperabduction-flexion, hyperflexion, hyperabduction-extension, hyperextension, and hyperextension-adduction.
Results: Hyperabduction-flexion was the most common mechanism (n = 16), in which interphalangeal joint dislocation and skin disruption was noted in most cases. The second most common mechanism was hyperabduction-extension (n = 14) in which avulsion fracture of the lateral volar condyle of the proximal phalanx was noted in most cases. This avulsion fracture had the worst prognosis after conservative care.
Conclusions: Based on these results, we have created a grading system and treatment protocol for indirect hallux sports injuries in children. Avulsion fracture of the lateral condyle of the proximal phalanx, a result of hyperabduction-extension, is a high-risk sign of nonunion and should be aggressively treated, contrary to previous guidelines.
Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.