Updated: 6/7/2021

Sesamoid Injuries of the Hallux

Review Topic
https://upload.orthobullets.com/topic/7010/images/Sesamoid fx_moved.jpg
https://upload.orthobullets.com/topic/7010/images/Transcervical fx - colorado_moved.png
https://upload.orthobullets.com/topic/7010/images/Sesamoid axillary view xray - Greer Richardson_moved.png
https://upload.orthobullets.com/topic/7010/images/Xray - courtesy of Richardson_moved.jpg
https://upload.orthobullets.com/topic/7010/images/Bone scan - courtesy Richardson_moved.jpg
https://upload.orthobullets.com/topic/7010/images/Sesamoid axial view illustration_moved.gif
  • summary
    • Sesamoid injuries of the Hallux consist of a constellation of injuries to the sesamoid complex consisting of fractures, tendonitis, and ligamentous injuries.
    • Diagnosis is suspected with hallux pain that is worse with hyperextension and can be confirmed with MRI studies.
    • Treatment depends on the specific injury to the sesamoid complex, chronicity and patient activity demands. 
  • Etiology
    • Specific injuries
      • fracture (caused by hyperextension and axial loading)
      • dislocation
      • sprain "turf toe"
      • sesamoiditis (trauma or infection)
      • chondromalacia
      • osteochondritis dissecans
      • FHB tendonitis
  • Epidemiology
    • Tibial sesamoid more commonly injured
      • has greater weight bearing status
      • larger than lateral sesamoid
  • Etiology
    • Mechanism
      • forced dorsiflexion of first MTP
        • most common
        • potential avulsion of plantar plate off base of phalanx
        • proximal migration of sesamoids
    • Associated conditions
      • bilateral sesamoiditis should raise alarm and concern for
        • reiter's disease (urethritis, conjuctivitis / iritis, inflammatory bowel disease)
        • psoriatic arthritis
        • seronegative RA
  • Anatomy
    • Osteology
      • sesamoids play important role in function of great toes by
        • absorbing weight-bearing pressure
        • reducing friction at MT head
        • protect FHL tendon
          • glides between sesamoids
        • provide fulcrum for flexor hallucis brevis that increases MTP flexion power
      • bipartite sesamoid present in 10-25%
        • 97% are in the tibial sesamoid
        • 25% bilateral
    • Attachments
      • FHB attaches to both tibial and fibular sesamoid
      • sesamoids are connected to each other by intersesamoid ligament and plantar plate
      • abductor hallucis is connected to tibial sesamoid
      • adductor hallucis is connected to fibular sesamoid
    • Biomechanics
      • sesamoid function is analogous to the patella as they increase the mechanical advantage of the FHB
  • Presentation
    • Symptoms
      • generalized big toe pain
        • worse in terminal part of stance phase
    • Physical exam
      • possible plantar-flexed MTP with cavus foot
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral of foot
        • medial oblique (sesamoid view)
        • axial sesamoid view
      • findings
        • proximal migration of sesamoids
          • be suspicious of intrinsic minus hallux
    • Bone scan
      • helps distinguish a bipartite sesamoid from a fracture
      • use caution with interpretation as 25%-30% of asymptomatic patients can have increased uptake
        • increased uptake compared to uninjured side helps diagnosis
  • Treatment
    • Nonoperative
      • NSAIDs, reduced weightbearing, activity modification, orthoses
        • indications
          • indicated as first line of treatment
      • short leg cast with toe extension
        • indication
          • acute fracture (controversial)
      • shaving keratotic lesion
        • indications
          • keratotic lesion present increasing pressure on sesamoids
    • Operative
      • partial or complete sesamoidectomy
        • indications
          • nonoperative management fails after 3-12 months
        • technique (see below)
      • autologous bone grafting
        • indications
          • nonunion or fracture
      • dorsiflexion osteotomy
        • indication
          • plantar-flexed first ray with sesamoid injury
  • Techniques
    • Complete or Partial Sesamoidectomy
      • approaches
        • approach to tibial sesamoid
          • medial-plantar approach
          • high risk of injuring proper branch of medial plantar nerve
        • approach to fibular sesamoid
          • plantar approach
          • beware for
            • proper branch to lateral side of hallux
            • first common branch to first web space
      • technique
        • may be partial or complete sesamoidectomy
        • sesamoid shaving (contraindicated in a patient with a plantar flexed 1st MT)
  • Complications
    • Cock-up deformity
      • removal of both sesamoids is associated with a high incidence of cock-up deformity of the great toe
      • caused by weakening of the flexor hallucis brevis tendon, which should be meticulously repaired after sesamoid excision
      • excision of both sesamoids should be avoided
    • Hallux valgus
      • may be caused from tibial sesamoid excision
    • Hallux varus
      • may be caused by fibular sesamoid excision

Please rate this review topic.

You have never rated this topic.

Thank you. You can rate this topic again in 12 months.

Flashcards (0)
1 of 0
Questions (7)

(SBQ12FA.79) Excision of the medial sesamoid of the great toe is indicated for which of the following presentations or procedures?

QID: 3886

Coupled with Lapidus procedure for hallux valgus



Recalcitrant medial sesamoid stress fracture with fragmentation



Acute medial sesamoid fracture



Coupled with first metatarsophalangeal joint arthrodesis for hallux rigidus



Morton's neuroma



L 1 C

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(OBQ12.23) A 32-year-old female avid triathlete complains of left plantar great toe pain for the past 4 months. She has failed conservative management. Her radiographs and bone scan are shown in Figures A and B. Which of the following surgical options would most reliably return her to sporting activities in a timely fashion?

QID: 4383

Tibial sesamoidectomy



1st metatarsophalangeal (MTP) plantar plate reconstruction



1st metatarsophalangeal (MTP) arthroscopy and debridement



Open reduction internal fixation of sesamoid with autogenous calcaneus bone graft



Distal 1st metatarsal chevron osteotomy with proximal phalanx Akin procedure



L 2 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(OBQ06.111) What is the most common surgical complication of resection of both the medial (tibial) and lateral (fibular) hallucal sesamoids on the same foot for intractable keratosis?

QID: 297

Hallux varus deformity






Toe cock-up deformity



Recurrence of keratosis



Hallux valgus deformity



L 2 D

Select Answer to see Preferred Response

Evidence (7)
Private Note