Updated: 10/26/2019

Sesamoid Injuries of the Hallux

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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 axial view illustration_moved.gif
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
Introduction
  • Sesamoid injuries include
    • 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
  • 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
Surgical 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
 

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Questions (6)
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(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? Review Topic

QID: 4383
FIGURES:
1

Tibial sesamoidectomy

74%

(3296/4425)

2

1st metatarsophalangeal (MTP) plantar plate reconstruction

5%

(209/4425)

3

1st metatarsophalangeal (MTP) arthroscopy and debridement

3%

(136/4425)

4

Open reduction internal fixation of sesamoid with autogenous calcaneus bone graft

15%

(666/4425)

5

Distal 1st metatarsal chevron osteotomy with proximal phalanx Akin procedure

2%

(92/4425)

L 2

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(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? Review Topic

QID: 297
1

Hallux varus deformity

8%

(288/3446)

2

Neuroma

1%

(44/3446)

3

Toe cock-up deformity

79%

(2708/3446)

4

Recurrence of keratosis

4%

(138/3446)

5

Hallux valgus deformity

7%

(257/3446)

L 2

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