Broken toe

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Broken toe
Other namesBedroom fracture, nightstand fracture, nightwalker fracture [1] [2]
X-rays of foot phalanx.jpg
X-rays of fractures of the proximal (left) and distal (right) phalanges in the little toe.
Specialty Emergency medicine
Symptoms Pain, tenderness, bruising, swelling, displacement of the bones. [3]
Complications Compromised blood circulation; malunion, long-term pain, degenerative joint disease, infection [3]
Usual onsetSudden [3]
CausesStubbing or crushing [3] over-extending a toe joint, stress fracture [3] [4]
Diagnostic method Visualisation, X-rays [3]
TreatmentFor pain and swelling, [3] rest, icing, elevation and pain medication; wearing wide, flat, comfortable, stiff-soled shoes; for smaller toes, buddy wrapping (taping the toe to the nearest toe, with some absorbent padding in-between); [4] [5] rarely, a cast or surgery [4]
Medication Over-the-counter painkillers [4]
Prognosis 4 to 8 weeks for full healing; pain lessens within days [4]
FrequencyCommon, [4] 8–9% of all fractures [6]

A broken toe is a type of bone fracture. [6] Symptoms include pain when the toe is touched near the break point, or compressed along its length (as if gently stubbing the toe). [3] There may be bruising, swelling, stiffness, or displacement of the broken bone ends from their normal position. [4]

Contents

Toes usually break because they have been stubbed or crushed. [3] [4] Crushing breaks are often caused by dropping something on the toe. [3] [4] More rarely, over-extending a toe joint can break off a portion of the bone, and stress fractures are possible, [3] especially just after a sudden increase in activity. [7] Diagnosis can be based on symptoms and X-rays. [4] [8]

Fractures of the smaller toes are usually treated with rest, buddy taping (taping the toe to the nearest toe, with some absorbent padding in-between), and wearing comfortable, wide-toed, flat, stiff-soled shoes. [5] [4] For pain and swelling of all toes, [3] rest, icing, elevation and pain medication are used. Pain usually decreases significantly within a week, but the toe may take 4–6 weeks to heal fully. [4] As activity is slowly increased to normal levels, the toe may be a bit sore and stiff. If the bone heals crooked, it may be relocated with or without surgery. [4] Broken toes can usually be cared for at home, unless the break is in the big toe, there is an open wound, or the broken ends of the bone are displaced. [4] In high-force crushing and shearing injuries, especially those with open wounds, blood circulation (tested by capillary refill) can be impaired, which needs urgent professional treatment. [3] More serious broken toes may need to be re-aligned or put in a cast; surgery is rarely needed. These cases may take longer (six to eight weeks) to heal fully. [4]

Broken toes are one of the most common types of fracture seen in doctor's offices, and make up just under 10% of fractures in some offices. [3]

Definition and classification

Toe bones or phalanges of the foot. Note the big toe has no middle phalanx.
People vary; sometimes the smallest toe also has none (not shown). [3]

   Distal phalanges of the foot
   Middle phalanges of the foot
   Proximal phalanges of the foot

Big toe fractures are treated differently from fractures of the lesser toes. [1] [9] Toe fractures may be articular (affecting the joint surfaces at the ends of the bone) or diaphyseal (between the ends). [10] They can be displaced, non-displaced, closed or open. [1]

The AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification generates numeric codes for describing broken toes. [10] They run 88[meaning a fracture of the phalanges].[number-code of toe, with the big toe=1 and the little toe=5].[number-code of phalanx, counting 1-3 outwards from the foot].[number-code of location on the bone, with 1 being the inner end, 3 the outer, and 2 in-between]. [10] So, for instance, 88.1.2.1 means a fracture to the big toe's innermost bone, at the proximal end. [10] [11] A letter can be added to describe the fracture pattern. [11]

Signs and symptoms

Broken toe with bruising and swelling Broken toe.jpg
Broken toe with bruising and swelling

Symptoms include pain when the site of the fracture is gently pressed, [8] or when the toe is gently compressed along its length [3] or moved. [7] There may be bruising or swelling; [8] sometimes there is a crackling sound. [8] There may be displacement of the bones; the alignment of the nail bed is compared to the same toe on the uninjured foot to check if the toe has rotated (see spiral fracture). [8]

Injuries to the nail bed and neurovascular bundles may be present. [8]

Complications

Diabetes can make foot injuries more serious, and those with diabetes are advised to have broken toes seen by a doctor. [5] Peripheral arterial disease can also be a complication. [7]

Malunion, healing with the bones out-of-place, can cause long-term pain and significant disability. Malunion of joint surfaces may cause degenerative joint disease. [3] Malunions may be corrected with or without surgery. [4]

When a toe is broken by crushing, there is often also a subungual hematoma (bleeding/bruising of the nail bed, under the toenail). [4] If there is enough blood to cause pain, it can be drained to relieve the pain and avoid (temporarily) losing the nail. [4] Draining is usually done if the injury is less than 24 hours old. Preserving the nail helps splint the broken toe. [3] Contaminated wounds are more serious; the wound should be kept clean. [10]

Broken toes with open wounds, especially if there is necrosis, can lead to osteomyelitis. [3] Joint problems are more likely in cases of involvement/possible displacement of the joint surface and, in children, involvement of the growth plate. [3] Degenerative arthritis of the distal (outer) big toe joint can occur as a complication of fractures, especially fractures to the proximal (inner) end and diaphysis (midsection) of the proximal bone. [10] If the proximal phalanx of the big toe is broken, hallux valgus (bunion) is a frequent complication. [10]

In high-force crushing and shearing injuries, especially those with open wounds, blood circulation can be impaired. [3]

Causes

Toes usually break because they have been stubbed or crushed. [3] [4] Crushing breaks are often caused by dropping something on the toe. [3] [4] More rarely, over-extending a toe joint can break off a portion of the bone, and stress fractures are possible, [3] especially just after a sudden increase in activity. [7]

Risk factors

Kicking the ground during sports may result in "turf toe" with an associated broken toe. [12] Getting up suddenly at night, particularly when barefoot, and having a forceful impact with furniture may lead to a broken toe, also called a "bedroom fracture" "nightstand fracture" or "nightwalker fracture". [1] [2] Although generally associated with the fifth toe and big toe, it can occur in any toe. [1] [13] In such a fracture, the hard blow to the tip of the distal phalanx typically results in a transverse or oblique fracture in the proximal phalanx (base of toe), but can occur in any phalanx. [1] [13] An open wound toe fracture may result from an injury from a lawn mower. [6] Although broken toes in horse riders are uncommon, riders are most likely to get broken toes when standing next to their horse. [14]

Mechanism

Because the big toe is more important for weight-bearing, balance, walking, and running, breaks to the big toe are more likely to be problematic. [8] [10] If the big toe is stubbed and breaks, it usually breaks the distal (outermost) bone. A crushing injury can break both big-toe bones. [10]

If the joint was bent too far (i.e. either hyperextended or hyperflexed) then spiral fractures and avulsion fractures are common. Spiral fractures with displacement make the toe rotate and shorten. With transverse fractures (i.e. across the toe), the toe may bend abnormally. [8]

Diagnosis

Broken toes are diagnosed by physically examining the toe, gently pressing on it, asking how it feels, and comparing it to the toe on the opposite foot [8] (see signs and symptoms, above). Blood circulation may be tested by capillary refill. [3]

It may be unclear whether the toe has a bone fracture or just a soft-tissue injury [5] (such as bruising, [5] sprains and tendon injuries [15] ). In these cases, it doesn't matter, because the treatment is usually the same for both types of injury. There is no need to figure out whether the toe is actually broken. [5] Follow-up X-rays also generally have no effect on treatment, and are unnecessary. [3]

X-rays are usually only taken if there are complications, or the toe is not healing as expected. [5] If X-rays are taken, the neighbouring toes and joints are also imaged. [8] If there is diffuse pain and tenderness across the foot, it may be necessary to X-ray the whole foot. [8] For displaced fractures, follow-up X-rays may be taken 3-6 weeks after injury. [3]

If a dislocated toe (a joint dislocation) is suspected, an X-ray may needed. [7]

In people with multiple traumas, foot trauma is often neglected. [10]

Treatment

It may not be clear whether the toe is broken or just bruised. [5] In such cases the treatment is usually the same in either case. [5]

Removing rings

Any rings on the toes are removed immediately, before the toe starts to swell. [16] [17] Pulling rings off forcefully may worsen the swelling. Relaxation, elevation, icing, lubrication (e.g. soapy water or oil), and rotating the ring as if unscrewing it may help. If these methods don't work, it may be possible to remove the ring by temporarily wrapping the toe with a slick thread (something like dental floss), passing the inner end of the thread under the ring and then unwrapping it, pushing the ring ahead of the unwrapping thread. Failing that, the ring may need to be cut off by a doctor. [18]

Reduction

If the fracture displaces the bones from their proper position (which it often doesn't), it needs to be reduced. Reduction puts the toe back into alignment, with all parts of the bones in the correct anatomical position. This is usually done by pulling gently along the length of the toe, then gently pulling the toe back into place. If there are multiple displaced bone fragments, shuffling them back into the correct positions may be more complicated. The fracture will usually stay in the correct position once re-aligned; if not, it needs more specialized treatment to hold the parts in place so that it heals straight. [3]

Stabilization and protection

Buddy-taping toes, using the most suitable adjacent toe to splint the broken toe.
Wider shoes allow the toes to lie straight. If the toes overhang when standing on the removed insole (right), then they will be cramped inside the shoe (left). VerbildeteFusseNormaleFusse.gif
Wider shoes allow the toes to lie straight. If the toes overhang when standing on the removed insole (right), then they will be cramped inside the shoe (left).
A walking boot Aircast walking boot1.JPG
A walking boot

Fractures of the smaller toes are commonly treated by buddy taping (see image). Padding is used between the toes to keep the space dry [4] and the toes aligned comfortably. If the toes are less comfortable when buddy-taped, the buddy tape should be removed. [7] Taping is not recommended for those with diabetes or peripheral arterial disease. [7]

It is also helpful for shoes to be stiff-soled (to protect the toe from bending), [4] low at the heel [5] (even a <2cm heel can increase pressure on the forefoot by over 20% [19] ), and wide. [20] [5] Most shoes, especially women's shoes, have a toe box which is more than a centimeter too tight; the width of the foot should be measured standing, with weight on it. [19] Comfortable shoes are recommended; tight, pointy shoes are undesirable. [5] If the top of the shoe is making the broken toe more painful, it is should be changed for something that won't, like open-toe sandals or old sneakers with the toe cut away. [16]

Somewhat more serious fractures which affect a joint, but with less than 2mm displacement and less than 25% of the area of the joint surface on the broken part, are generally also be treated with buddy taping and suitable shoes; the evidence on this treatment is not extensive. [8]

Fractures with displacement at the break, including rotation, can often be reduced (re-aligned) by a family doctor. Some broken toes may need to be put in casts, especially if the fracture is unstable (it won't stay reduced on its own). [3] [4] If more than 25% of the area of the joint surface was on the broken-loose part, or the break had to be reduced, follow-up X-rays are done 7–10 days afterwards. [8]

Fractures of the big toe are treated with a short-leg orthopedic walking boot, or a short-leg walking cast with a sole that protrudes beyond the big toe. These are worn for 2–3 weeks. Buddy taping and a rigid sole are then used for 3–4 weeks, if symptoms allow. At four weeks, range-of-motion exercises can start. If the joint was involved or the break had to be reduced, follow-up X-rays are done a week afterwards. [8]

Pain and swelling

Activities which cause pain should be avoided, and resumed slowly as the toe heals. [4]

To reduce pain and swelling, [3] rest, ice, elevation and over-the-counter pain medication are used. The toe is chilled with ice 20 minutes of every hour for the first waking day, and 2-3 times a day afterwards. Ice is not put directly on the skin. [4]

Surgical

Surgery is not needed for most broken toes, [4] but may involve fastening bits of toe bone together with wires, screws, or screwed plates. [10] Such procedures are within the scope of orthopaedic surgery.

Prognosis

Complete healing may take four to six weeks, and complex cases may take up to eight weeks. [4] Some athletes may need longer. [8] Long-term disability is rare. [3] (see complications section).

Epidemiology

Approximately 8 to 9% of all broken bones are of a toe. [6] Studies have varied as to whether broken big toes are more or less common than broken lesser toes. [1] In a UK study involving nearly 6000 fractures seen in hospital, 3.6% were broken toes. [10] Fractures of big toes make up about a fifth [3] or third [8] of all toe fractures, and 5.5% of all foot and ankle fractures in major US trauma hospitals. [10] Toe fractures are the most common foot fractures. [8] About 20% of broken toes involve open wounds. [10]

Other animals

Buddy strapping can be used for toe fractures in big birds. [21] Sometimes a ball bandage can be used, where the bird curls its toes over it. [21] Due to pneumatic bones in birds, washing an open toe fracture may be harmful. [21] Broken toes in grebes can be splinted but if dislocated, often require amputation. [22] A toe fracture in an elephant may go unnoticed. [23] [24] Knocked-up toes in racing greyhounds may be mistaken for a toe fracture. [25]

See also

Related Research Articles

<span class="mw-page-title-main">Foot</span> Anatomical structure found in vertebrates

The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws and/or nails.

<span class="mw-page-title-main">Toe</span> Digit of a foot

Toes are the digits of the foot of a tetrapod. Animal species such as cats that walk on their toes are described as being digitigrade. Humans, and other animals that walk on the soles of their feet, are described as being plantigrade; unguligrade animals are those that walk on hooves at the tips of their toes.

<span class="mw-page-title-main">Bunion</span> Deformity characterized by lateral deviation of the big toe

A bunion, also known as hallux valgus, is a deformity of the MTP joint connecting the big toe to the foot. The big toe often bends towards the other toes and the joint becomes red and painful. The onset of bunions is typically gradual. Complications may include bursitis or arthritis.

<span class="mw-page-title-main">Metatarsal bones</span> Five long bones in the foot

The metatarsal bones or metatarsus are a group of five long bones in the midfoot, located between the tarsal bones and the phalanges (toes). Lacking individual names, the metatarsal bones are numbered from the medial side : the first, second, third, fourth, and fifth metatarsal. The metatarsals are analogous to the metacarpal bones of the hand. The lengths of the metatarsal bones in humans are, in descending order, second, third, fourth, fifth, and first. A bovine hind leg has two metatarsals.

<span class="mw-page-title-main">Bone fracture</span> Physical damage to the continuity of a bone

A bone fracture is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a comminuted fracture. A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

<span class="mw-page-title-main">Hammer toe</span> Rigidly clenched toe due to deformity of related muscles or ligaments

A hammer toe, hammertoe or contracted toe is a deformity of the muscles and ligaments of the proximal interphalangeal joint of the second, third, fourth, or fifth toe, bending it into a shape resembling a hammer. In the early stage, a flexible hammertoe is movable at the joints; a rigid hammertoe joint cannot be moved and usually requires surgery.

<span class="mw-page-title-main">Joint dislocation</span> Medical injury

A joint dislocation, also called luxation, occurs when there is an abnormal separation in the joint, where two or more bones meet. A partial dislocation is referred to as a subluxation. Dislocations are often caused by sudden trauma on the joint like an impact or fall. A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves. Dislocations can occur in any major joint or minor joint. The most common joint dislocation is a shoulder dislocation.

<span class="mw-page-title-main">Stress fracture</span> Bone fracture due to repeated stressing

A stress fracture is a fatigue-induced bone fracture caused by repeated stress over time. Instead of resulting from a single severe impact, stress fractures are the result of accumulated injury from repeated submaximal loading, such as running or jumping. Because of this mechanism, stress fractures are common overuse injuries in athletes.

<span class="mw-page-title-main">Phalanx bone</span> Digital bone in the hands and feet of most vertebrates

The phalanges are digital bones in the hands and feet of most vertebrates. In primates, the thumbs and big toes have two phalanges while the other digits have three phalanges. The phalanges are classed as long bones.

<span class="mw-page-title-main">Jones fracture</span> Fracture of the fifth metatarsal bone of the foot

A Jones fracture is a broken bone in a specific part of the fifth metatarsal of the foot between the base and middle part that is known for its high rate of delayed healing or nonunion. It results in pain near the midportion of the foot on the outside. There may also be bruising and difficulty walking. Onset is generally sudden.

<span class="mw-page-title-main">Ankle fracture</span> Medical condition

An ankle fracture is a break of one or more of the bones that make up the ankle joint. Symptoms may include pain, swelling, bruising, and an inability to walk on the injured leg. Complications may include an associated high ankle sprain, compartment syndrome, stiffness, malunion, and post-traumatic arthritis.

A traction splint most commonly refers to a splinting device that uses straps attaching over the pelvis or hip as an anchor, a metal rod(s) to mimic normal bone stability and limb length, and a mechanical device to apply traction to the limb.

<span class="mw-page-title-main">Interphalangeal joints of the foot</span> Hinge joints connecting the phalanx bones of each toe

The interphalangeal joints of the foot are the joints between the phalanx bones of the toes in the feet.

<span class="mw-page-title-main">Salter–Harris fracture</span> Bone fracture, especially in children

A Salter–Harris fracture is a fracture that involves the epiphyseal plate of a bone, specifically the zone of provisional calcification. It is thus a form of child bone fracture. It is a common injury found in children, occurring in 15% of childhood long bone fractures. This type of fracture and its classification system is named for Robert B. Salter and William H. Harris who created and published this classification system in the Journal of Bone and Joint Surgery in 1963.

<span class="mw-page-title-main">Jammed finger</span> Medical condition

Jammed finger is a colloquialism referring to a variety of injuries to the joints of the fingers, resulting from axial loading beyond that which the ligaments can withstand. Common parts of the finger susceptible to this type of injury are ligaments, joints, and bones. The severity of the damage to the finger increases with the magnitude of the force exerted by the external object on the fingertip. Toes may become jammed as well, with similar results.

<span class="mw-page-title-main">March fracture</span> Fracture of the metatarsal bones of the foot due to recurrent stress

March fracture is the fracture of the distal third of one of the metatarsal bones occurring because of recurrent stress. It is more common in soldiers, but also occurs in hikers, organists, and other people whose duties entail much standing. March fractures most commonly occur in the second and third metatarsal bones of the foot. It is a common cause of foot pain, especially when people suddenly increase their activities.

<span class="mw-page-title-main">Coffin bone</span> Bone in the hoof of hoofed animals

The coffin bone, also known as the pedal bone (U.S.), is the distal phalanx, the bottommost bone in the front and rear legs of horses, cattle, pigs and other ruminants. It is encased by the hoof capsule. In horses and other odd-toed ungulates it is the third phalanx, or "P3"; in even-toed ungulates such as cattle, it is the third and fourth. The coffin bone meets the short pastern bone or second phalanx at the coffin joint. The coffin bone is connected to the inner wall of the horse hoof by a structure called the laminar layer. The insensitive laminae coming in from the hoof wall connects to the sensitive laminae layer, containing the blood supply and nerves, which is attached to the coffin bone. The lamina is a critical structure for hoof health, therefore any injury to the hoof or its support system can in turn affect the coffin bone.

<span class="mw-page-title-main">Hand</span> Extremity at the end of an arm or forelimb

A hand is a prehensile, multi-fingered appendage located at the end of the forearm or forelimb of primates such as humans, chimpanzees, monkeys, and lemurs. A few other vertebrates such as the koala are often described as having "hands" instead of paws on their front limbs. The raccoon is usually described as having "hands" though opposable thumbs are lacking.

Theropod paleopathology is the study of injury and disease in theropod dinosaurs. In 2001, Ralph E. Molnar published a survey of pathologies in theropod dinosaur bone that uncovered pathological features in 21 genera from 10 theropod families. Pathologies have been seen on most theropod body parts, with the most common sites of preserved injury and disease being the ribs and tail vertebrae. The least common sites of preserved pathology are the weight-bearing bones like the tibia, femur and sacrum. Most pathologies preserved in theropod fossils are the remains of injuries, but infections and congenital deformities have also been documented. Pathologies are less frequently documented in small theropods, although this may simply be because the larger bones of correspondingly larger animals would be more likely to fossilize in the first place.

<span class="mw-page-title-main">Broken finger</span> Medical condition

A broken finger or finger fracture is a common type of bone fracture, affecting a finger. Symptoms may include pain, swelling, tenderness, bruising, deformity and reduced ability to move the finger. Although most finger fractures are easy to treat, failing to deal with a fracture appropriately may result in long-term pain and disability.

References

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  9. ↑ Sueki, Derrick; Brechter, Jacklyn (2009). Orthopedic Rehabilitation Clinical Advisor. Maryland Heights: Elsevier. p. 686. ISBN   978-0-323-05710-3.
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  11. 1 2 Meinberg, Eg; Agel, J; Roberts, Cs; Karam, Md; Kellam, Jf (January 2018). "Fracture and Dislocation Classification Compendium—2018" (PDF). Journal of Orthopaedic Trauma. 32 (1): S1–S10. doi:10.1097/BOT.0000000000001063. PMID   29256945. S2CID   39138324., page 99 of PDF fulltext
  12. ↑ Rowe, Lindsay J. (1995). "4. Imaging". In Logan, Alfred L.; Rowe, Lindsay J. (eds.). The Foot and Ankle: Clinical Applications. Gaithersburg, Maryland: Jones & Bartlett Learning. pp. 76–78. ISBN   0-8342-0605-6.
  13. 1 2 Yochum, Terry R.; Rowe, Lindsay J.; Maola, Chad J. (2005). "9. Trauma". In Yochum, Terry R.; Rowe, Lindsay J. (eds.). Essentials of skeletal radiology (Third ed.). Baltimore: Lippincott Williams & Wilkins. pp. 881–884.
  14. ↑ Ceroni, Dimitri (1 January 2007). "Support and safety features in preventing foot and ankle injuries in equestrian sports : review article". International SportMed Journal. 8 (3): 166–178. hdl:10520/EJC48619.
  15. ↑ Hatch, Robert L.; Hacking, Scott (15 December 2003). "Evaluation and Management of Toe Fractures". American Family Physician. 68 (12): 2413–2418. ISSN   0002-838X. PMID   14705761.
  16. 1 2 "Toe Injury". Seattle Children's Hospital. Retrieved 5 December 2021.
  17. ↑ Zuber, Thomas J.; Mayeaux, E. J. (2004). "6. Ring removal". Atlas of Primary Care Procedures. Philadelphia: Lippincott Williams & Wilkins. pp. 51–52. ISBN   978-0-7817-3905-4.
  18. ↑ "Removing a Ring From a Finger or Toe". HealthLink BC. Archived from the original on November 13, 2021. Retrieved November 13, 2021.
  19. 1 2 Coughlin, MJ; Thompson, FM (1995). "The high price of high-fashion footwear" (PDF). Instructional Course Lectures. 44 (10): 371–7. doi:10.2106/00004623-199410000-00022. PMID   7797875. S2CID   29979737. Archived from the original (PDF) on 2019-11-18.
  20. ↑ "Toe and Forefoot Fractures". www.orthoinfo.org. OrthoInfo. American Academy of Orthopaedic Surgeons.
  21. 1 2 3 Sirois, Margi (2021). "13. Avian and exotic animal care and nursing". Elsevier's Veterinary Assisting Textbook (3rd ed.). St. Louis, Missouri: Elsevier. p. 384. ISBN   978-0-323-68145-2.
  22. ↑ Duerr, Rebecca S.; Gage, Laurie J. (2020). Hand-Rearing Birds (2nd ed.). Hoboken: Wiley Blckwell. p. 172. ISBN   978-1-119-16775-4.
  23. ↑ Fowler, Murray E. (2008). "20. Foot disorders". In Fowler, Murray E.; Mikota, Susan K. (eds.). Biology, Medicine, and Surgery of Elephants. Ames, Iowa: Blackwell Publishing. p. 288. ISBN   978-0-8138-0676-1.
  24. ↑ Regnault, Sophie; Dixon, Jonathon J.I.; Warren-Smith, Chris; Hutchinson, John R.; Weller, Renate (18 January 2017). "Skeletal pathology and variable anatomy in elephant feet assessed using computed tomography". PeerJ. 5: e2877. doi: 10.7717/peerj.2877 . ISSN   2167-8359. PMC   5248576 . PMID   28123909.
  25. ↑ McCunn, J.; Formston, C. (1 March 1931). ""Knocked -Up Toe" in Racing Greyhounds". The Veterinary Journal. 87 (3): 144–147. doi:10.1016/S0372-5545(17)40566-9. ISSN   0372-5545.
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