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Sesamoid Fracture

Details:

The sesamoid bones are a pair of small bones located on the plantar aspect (bottom) of the great toe joint. The sesamoids bones function tosesamoid_fracture transfer the force of the flexor hallucis brevis (FHB) tendon as it rounds the undersurface of the great toe joint. You can compare the function of the sesamoid bones to that of the knee cap (patella). Both the sesamoids and the patella facilitate the transfer of force generated by a muscle around a joint.

Sesamoid fractures can be the result of a direct force applied to the sesamoid such as in a fall from a height. Sesamoid fractures can also occur as a result of a traction force. A traction force is created by the FHB pulling against the sesamoid while the hallux if held in a fixed position. Sesamoid fractures can also occur secondary to loss of blood flow to the sesamoid. This condition is called avascular necrosis, or AVN.

Sesamoid fractures occur most commonly through the mid body of the sesamoid. Less frequently we'll see avulsion of the distal ligament of the sesamoid as seen in the x-ray image (right). bone_scan_for_sesamoid_fracture

Diagnosis of a sesamoid fracture is often made with an x-ray. Subtle sesamoid fractures can also be diagnosed with MRI or a bone scan. The image at left shows a bone scan suggesting a fracture of the right tibial sesamoid. Although bone scans cannot specifically diagnose a sesamoid fracture, they can reveal areas of inflammation consistent with a fracture.bipartite_sesamoid

Sesamoid fractures need to be differentiated from bipartite, or two part sesamoids.  Bipartite sesamoids are found in less than 10% of the general population.  Bipartite sesamoids are usually found bilaterally.  Therefore, one way to differentiate a bipartite sesamoid from a fractured sesamoid is to take a comparison x-ray of the non-symptomatic foot.  Bipartite sesamoids usually have a rounded appearance at the separation of the two fragments while fractures are typically sharp edged, without rounded edges.

Treatment of Sesamoid Fractures

The treatment of sesamoid fractures begins with a period of conservative care. Treatment during this conservative period includes decreased periods of weight bearing and limitations of activities. Most patients who have a sesamoid fracture can remain ambulatory with just a few simple changes to weight bearing. The first way in which weight bearing can be changed is called off-loading of the sesamoid. Thesesamoid_fracture sesamoid can be off loaded with the use of a dancer's pad or forefoot reliever off loading shoe. A cam walker with a rocker sole can also be helpful in reducing load to the sesamoid while healing. This period of off-loading may last 6-8 weeks.

The most common outcome of a sesamoid fracture is that the fracture heals with an asymptomatic fibrous union. This fibrous union is not true bone but rather a tissue made of collagen that is strong enough to support the normal function of the sesamoid. Often we'll see that this fibrous union is adequate for some activities but becomes painful with sports or increased duration of time on the feet. If this is the case, patients will experience transient pain with increased activity. High heeled shoes also will aggravate a fibrous union of a sesamoid fracture.

Some sesamoid fractures will not heal and present with continued pain. If this is the case, surgical excision of the sesamoid called a sesamoidectomy is performed. The tibial (medial sesamoid) is excised through a 3-4 cm incision on the medial aspect of the great toe joint. The fibular sesamoid is excised either through a dorsal (top of the foot) incision or a plantar (bottom) incision. The plantar incision affords a better approach to the fibular sesamoid but necessitates 3 weeks non-weight bearing following surgery to avoid direct pressure to the plantar incision. Many surgeons prefer to excise the fibular sesamoid through a dorsal approach to enable immediate weight bearing on the foot post-op.

Partial sesamoidectomy for sesamoid fractures is rarely advocated by surgeons due to consistently poor outcomes of this procedure. Fixation of sesamoid fractures is also an uncommon technique used in treating sesamoid fractures. Most surgeons will avoid using pin, screw or absorbable fixation due to the high success rate of traditional, complete sesamoidectomy.

A sesamoidectomy (both tibial and fibular) can be performed at a hospital or surgery center on an out-patient basis. Local anesthesia with sedation is the preferred anesthetic. Partial to full weight bearing is possible post-op depending on the incision site. No weight bearing for three weeks is the rule for plantar incisions used to access the fibular sesamoid. Most sesamoidectomies heal uneventfully in 6-8 weeks.

The images below show the steps used to perform a tibial sesamoidectomy. Image 1 shows the incision planning. Image 2 shows exposure of the tibial sesamoid and dissection of the sesamoid from its' attachments to the capsule of the 1st metatarsal phalangeal joint. Image 3 shows that joint following excision of the sesamoid. The surgical void is inspected to insure no damage occurred to the flexor hallucis longus. Image 4 shows final closure and image 5 shows an intact but fractured tibial sesamoid.

tibial_sesamoid_fracture_surgery tibial_sesamoid_fracture_surgery tibial_sesamoid_fracture_surgery tibial_sesamoid_fracture_surgery tibial_sesamoid_fracture_surgery


Nomenclature:

1st metatarsal phalangeal joint - the big toe joint. Often referred to as the 1st MPJ or great toe joint.

'itis' - suffix used to describe inflammation.

plantarflex - to move down toward the plantar surface (or floor), away from the shin.

sesamoid - derived from Greek referring tosesame seed.


Anatomy:

Anatomy_flexor_hallucis_brevis_muscleThe two sesamoid bones are located on the bottom surface of the first metatarsal phalangeal joint. The sesamoids are actually a working part of the 1st MPJ and articulate with the plantar surface of the first metatarsal. The sesamoid bones are an extension of the flexor hallucis brevis (FHB) muscle and give the FHB a greater range of motion and improved lever action at the level of the 1st MPJ.

Sesamoid bones are referred to by their location and are called the tibial sesamoid (medial) and the fibular sesamoid (lateral). Tibial and fibular make reference to the bones of the lower leg; the tibia and fibula.

Sesamoid bones are most common to the 1st MPJ but may also be found at other tendon/joint surfaces where a tendon changes direction. 


Biomechanics:

The flexor hallucis brevis muscle (FHB) originates on the plantar surface of the calcaneus (heel bone). The function of the FHB is to plantarflex the great toe. The primary function of the FHB is to aid in balance and assist the calf with the toe off phase of gait. As the FHB fires, the load generated by the body of the muscle is sent through the sesamoid to an extension of the FHB that attaches to the plantar aspect of the great toe. The net result is that the great toe plantarflexes using the sesamoid bones to glide around the plantar surface of the 1st MPJ.


Symptoms:

The onset of a sesamoid fracture can be acute or insidious. In some, but not all cases, a specific activity is related to the onset of pain. Initially, swelling is not severe but may increase over time. Swelling is usually specific to the plantar (bottom) aspect of the great toe joint. Pain is found with the onset of weight bearing and increases with the duration of time on the feet.


Differential Diagnosis:

Arthritis

Bunion

Chondromalacia

Gout

Hallux limitus

Infection of the joint (septic joint)

Pseudogout

Sesamoiditis


Products Recommended for Sesamoid Fracture:

See Also:

References:

This article was written by Jeffrey A. Oster, DPM and last updated 4/20/10. No additional references are available for this topic.


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