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Somewhere in the last few days someone - possibly Simon - asked how you differentiate between bipartite and a fractured sesamoid. Can't locate the thread or post, however I recently had a patient with 1st MTPJ pain who presented with a bipartite medial sesamoid - and two seperate radiologists diagnosed a bipartite and then a fractured sesamoid. My understanding is that a bipartite sesamoid appears fully corticated on X-ray whilst a fracture shows a more irregular margin. But not always. Probably the best diagnostic aproach is with a CT scan. That said, I look forward to other views....

 

here is the thread you were talking about Mark

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=42749

 

Thank's Michael - grateful that you don't have the same memory problems as I do!

 

Mark:

I will tend to use MRI in these examples since MRI will allow you to also see bone edema.

 

Kevin

Good point. What does BME in sesamoids indicate aside from local trauma? Pre-fracture or osteopenia?

Happy New Year BTW.

 

A bipartite sesamoid will generally appear as 2 seperate bones with their own corticies and generally I've found them to be further appart than fractured sesamoid bones. Fractures in sesamoids are often a lot finer, and appear more as a sclerotic line without the cotical bone either side of it.

A good set or X-rays, including and axial sesamoid view, especially if you can get the digital diacom image, is as usefull as anything in my experience to seeing sesamoid fracture. Although sometimes convincing GPs that the fracture is there can be difficult. Bone scan usually confirms it for me, has in the past.

Cheers!

 

But not always.
I had an interesting case a few years back with a professional runner.
Symptoms suggested a fractured sesamoid, xray inconclusive- a possible line, but not reported as an abnormality. Bone scan was cold.
Was treated as sesamoiditis, but but did not improve.
Follow up xray a few weeks later was then conclusive as there was as separation in the sesamoid.
Follow up MRI showed it clearly.
Interestingly, we managed it successfully with orthoses and rest.

 

G'Day Craig,

Interesting case! I guess if it's early enough and given that sesamoid bones are fairly avascular, there could be the potential for delayed uptake in the bonescan?

Cheers!

 

I have previously utilised only Xray plain film although as the comments suggest not always clearly defined.
fMRI has a clear advantage over other diagnostic imaging less of course the cost and time implications

 

Hi Craig,

I'm interested in knowing what type of orthoses script you managed the runner with 'sesamoiditis' - was there anything in the script that you would change for this condition, or just base it on your biomechanical assessment.

I currently have a patient who has increased his running, is also on his feet >6hrs for work who has pain over his medial/tibial sesamoid (and also minor over fibular sesamoid) also pain on DFlexion of 1st mpj and on isometric contraction of FHB>FHL.

I have flask taped him for the moment and offloaded with a winged 1st plantar pad, and sent him for xrays. I got the xrays back today and they demonstrate bilateral bipartite sesamoids. They sit a fair way apart but are not smooth so am not sure if possibly could be fractured as well.

I plan on continuing to pad and offload, but would appreciate your views on orthoses as par tof mx.

cheers,

Bianca

cheers,,

Bianca

 

woops posted twice.

 

Hi Bianca
From memory I looked at all components of his foot mechanics which were causing plantar 1st MTPJ overload and addressed them.
He had a high axis STJ with increased pronatory forces so the device had more transverse plane control (it closely matched his high MLA) with a degree of inversion control. In additon there was an EVA extension under 2-5.
There was a bit of fine tuning to optimise fit. I manufacture all my own devices, and this was a case where I feel this was advantageous to get the best result.