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Updated: Jun 7 2021

Sesamoid Injuries of the Hallux

Images fx_moved.jpg fx - colorado_moved.png axillary view xray - Greer Richardson_moved.png - courtesy of Richardson_moved.jpg scan - courtesy Richardson_moved.jpg 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
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