Atrophic Nonunion in Fifth Toe Fractures: A Case Report Linking Occult Infection and Fifth Toe Fracture

Phalangeal fractures are the most common fractures in the foot, with the vast majority completely healing with conservative management. The overall nonunion rate for fractures of the lesser phalanges is not well documented in the literature due to their rarity. The following cases explore two unusual presentations of fifth toe closed fracture with delayed union, suggesting a potential link between infection and delayed healing in apparently closed fractures. The first patient, a 46-year-old female with a history of smoking and synphalangism, developed persistent pain and swelling following a toe fracture. Imaging confirmed atrophic nonunion, and cultures from her eventual amputation identified Clostridium species, suggesting occult infection as a contributing factor. The second patient, a 59-year-old female with anemia and synphalangism, presented with delayed healing of a similar fracture. Empirical antibiotic treatment resulted in complete resolution of symptoms and radiographic healing, further supporting a potential infectious etiology. Occult infection may be a contributing factor in cases of delayed union, even for closed toe fractures. Empirical antibiotic therapy may be a viable nonoperative approach in select patients. Further studies are needed to investigate infection as a potential etiology of atrophic nonunion in closed toe fracture healing in order to guide optimal management strategies.