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Hi all,

I saw a patient the other day that was complaining of 1st MPJ pain. She has a mild bunion with an associated medial bursa which we are attempting to manage. She also has moderate pain palpable on the fibula sesamoid.

I ordered an x-ray to check the joint and the report commented on a mild HAV but otherwise unremarkable.

The images however, suggest a possible small fracture to the proximal part of the fibula sesamoid. Just wondering if someone could take a look at the attached images and see if my suspicions are correct? It might be hard to see on attached images but is much clearer when I view them on the inteleviewer when I can zoom in on the sesamoid.

If my suspicion is correct what do you think the likelyhood is of this fracture healing, given that it has probably been there for some time? The patient does have poor bone density and is taking Fosamax. There also seems to be a generally strange appearance to the sesamoid, almost subchondral cyst like appearances.

What do you suggest is the best course of treatment for this patient?

Regards

 

It looks like a fracture. As the two parts are separated it appears to be a traction injury. That is, the two halves of the sesamoid are pulled apart. Thinking in terms of tissue stress, how to lower tension on the sesamoids. The plantar fascia attaches to the sesamoids as do the intrinsic muscles of the first ray. A dorsiflexion moment on the hallux will be resisted by a proximal pull from the ligaments attached to the distal half of the sesamoids. A dorsiflexion moment occurs at the hallux during heel lift in gait. So treat this by decreasing tension on the plantar fascia and prevent dorsiflexion of the hallux.

I'm going to skip a few steps in the rationale. Incrase supination moment from the ground. Put a hole under the first met head (reverse morton's) and consider a rigid rocker bottom shoe.

Amazingly, these recomendations are remarkably similar to what you would do if someone had sesamoiditis from high plantar pressures. So, it does not really matter whether it was fractured or not. The problem is the continued high stress not the fibrous tissue that has formed betwen the two halves of the sesamoid >6 weeks after the fracture. Treat the pain not the x-rays

Cheers,

Eric

 

I'd say arthritic with cyctic changes, I do not see a Fx though. Only two views makes occult Fx difficult to see.

I'd call it sesamoiditis, no Fx.

Steve

 

G'Day

From what i can see of the X-rays of the fibial sesamoid, the pattern of sclerosis and shadow seems to be inline with the idea of a delayed healing stress fracture under tension. Offload it, reduce pull from plantar soft tissue structures and that shoudl help. You'll be surprised how much you can reduce the forces under that 1st MTPJ by using a thin plantar cover (2mm-ish) of 220(ish) EVA with an aperature under teh 1st MTPJ, stuck into the shoe. Whilst you're at it, an arch cookie will help supinatory forces and is temporary. Failing this, stick the patient in a camm walker....

One point of interest, with sesamoid pain and X-rays, I'll usually get and 'axial sesamoid' view, which is a frontal plane view with the ankle plantarflexed and the hallux dorsiflexed. Visualises the sesamoids brillinatly and their articulation with the 1st MTPJ.

Good luck!

 

The # is visible quite clearly when you zoom in on the fibular sesamoid on the MO view.

I usually overtreat these after a couple went on the AVN -> CAM walker for 4-6 weeks followed by appropriate orthosis to offload the 1st MTP joint.

LL