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Hallux Sesamoid Fracture

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Other Names

  • Sesamoid stress fracture
  • Sesamoiditis
  • Hallucal Sesamoid Fractures
  • Stress fractures of the great toe sesamoids (SFGTFs)
  • Sesamoiditis

Background

  • This page refers to fractures of the Hallux Sesamoid
    • This includes both acute, traumatic fractures and overuse, stress fractures

History

Epidemiology

  • Prevalence
    • Represents about 1-3% of all stress fractures[1]

Pathophysiology

  • General
    • Overall, the literature on sesamoid fractures is sparse
    • Should be considered in any patient presenting with unexplained great toe pain
  • Location
    • Approximately 75% of cases occur on the medial (tibial) sesamoid
    • Hypothesized due to medial sesamoid’s location under the first metatarsal head[2]
  • Considered high risk due to
    • Precarious and variable blood supply and sheering forces across the bone may hinder or prevent healing[3]
    • Increase the risk of delayed or non-union
    • High risk of injury reoccurrence[4]
  • Bilateral sesamoiditis should raise concern for

Etiology

  • Stress fractures
    • Commonly injured from sports involving forced repetitive dorsiflexion of the great toe
    • See: Stress Fractures (Main)

Pathoanatomy

  • Hallux Sesamoid
    • There are two sesamoids, medial (tibial) and lateral (fibular)
    • Located plantar to the first metatarsal, in the medial and lateral slips of Flexor Hallucis Brevis tendon
    • Complex consists of 8 ligaments, 7 muscles, and 2 sesamoid bones[5]
  • Function
    • Integral role in first metatarsophalangeal joint function[6]
    • Increases mechanical advantage of Flexor Hallucis Brevis (similar to patella)
    • Can absorb approximately 80% of the body mass during a bipedal barefoot gait[7]
    • Subjected to forces several times greater than body weight, especially upon landing from jump[8]

Risk Factors

  • Sports
    • Dance
    • Gymnastics
    • Running
    • Soccer
    • Football

Differential Diagnosis


Clinical Features

  • History
    • The patient will present with unexplained toe pain
    • History may be acute or subacute/ insidious depending on etiology of the sesamoid fracture
    • Stress fractures present with exercise related pain on the plantar aspect of the 1st MTP joint
  • Physical Exam: Physical Exam Foot
    • Tenderness in the plantar region of the first metatarso-phalahgeal joint
    • Range of motion is typically intact, but passive or exaggerated dorsiflexion can often reproduce symptoms
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Often normal or non-diagnostic
  • Axial sesamoid view
    • Beam is projected through the sesamoid in an axial plane
  • Bipartite Sesamoid
    • Present in 10 - 25% of individuals (need citation)
    • 97% are tibial, 25% are bilateral (need citation)
    • Common and easily confused for a fracture
    • Also do not exclude the possibility of a fracture

MRI

  • Second line imaging in patients with suspected stress fracture

CT

  • Consider in patients where suspected traumatic fracture is radiographically occult

Classification

  • Not applicable

Management

  • General
    • Limited evidence to direct the management of both stress and traumatic sesamoid fractures

Nonoperative

  • Indications
    • Vast majority of cases
    • First line for all stress fractures
    • Nondisplaced and minimally displaced fractures
  • General
  • Activity modification
    • For patients with stress injuries, modification of activities will last 2 to 6 months
  • Immobilization
  • Weight bearing status
    • Stress fractures should be made non weight bearing for up to 6 weeks
    • Acute fractures can range from non-weight bearing to a removable boot
    • York et al treat acute fractures with immobilization with the toe in plantarflexion for 4-6 weeks[9]
  • Additional considerations for stress fractures

Operative

  • Indications
    • Displaced acute fractures
    • Failure of conservative management of stress fractures
    • Athletes looking for an quicker return to play
    • Nonunion or malunion
  • Technique
    • Percutaneous screw fixation
    • Internal fixation
    • Curettage
    • Bone grafting
    • Partial or complete sesamoidectomy

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Most athletes are able to return to play and sport
    • Time to return to sport ranges from about 3 - 5 months

Complications and Prognosis

Prognosis

  • Surgical outcomes
    • Sesamoidectomy results in fastest return to sport[10]
    • Internal fixation results in the best chance of returning to the previous level of sport[10]
  • Surgical vs non-surgical management of stress fractures
    • No difference in return to sport rates, however surgical patients returned faster (11 weeks) compared to non-surgical (14 weeks)[10]
    • With conservative management, 86% of athletes will return to sport, only 64% to pre-injury level of competition[10]
  • Return to sport
    • Close to 85% of patients became pain free and/or were cleared for full sports participation, mean recovery time 5 months[11]

Complications

  • Inability to return to sport
  • Chronic pain
  • Nonunion
  • Malunion
  • Cock-up deformity
  • Hallux valgus
  • Hallux varus

See Also


References

  1. Iwamoto J, Sato Y, Takeda T, et al. Analysis of stress fractures in athletes based on our clinical experience. World J Orthop. 2011;2:7–12.
  2. Biedert R, Hintermann B. Stress fractures of the medial great toe sesamoids in athletes. Foot Ankle Int. Feb 2003;24(2):137-141.
  3. Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress fractures of the foot and ankle in athletes. Sports Health. Nov 2014;6(6):481-491.
  4. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. Nov-Dec 2000;8(6):344-353.
  5. Alvarez R, Haddad RJ, Gould N, et al. The simple bunion: anatomy at the metatarsophalangeal joint of the great toe. Foot Ankle. 1984;4:229–240.
  6. Stein CJ, Sugimoto D, Slick NR, et al. Hallux sesamoid fractures in young athletes. Phys Sportsmed. 2019;47:441–447.
  7. McBride ID, Wyss UP, Cooke TD, et al. First metatarsophalangeal joint reaction forces during high-heel gait. Foot Ankle. 1991;11:282–288.
  8. Ribbans WJ, B H. Hallucal Sesamoid Fractures in Athletes: Diagnosis and Treatment. Sports Orthopaedics and Traumatology. 2016;32:295-303.
  9. York PJ, Wydra FB, Hunt KJ. Injuries to the great toe. Curr Rev Musculoskelet Med. Mar 2017;10(1):104-112.
  10. 10.0 10.1 10.2 10.3 Robertson GAJ, Goffin JS, Wood AM. Return to sport following stress fractures of the great toe sesamoids: a systematic review. Br Med Bull. Jun 1 2017;122(1):135-149.
  11. Stein, Cynthia J., et al. "Hallux sesamoid fractures in young athletes." The Physician and sportsmedicine 47.4 (2019): 441-447.
Created by:
John Kiel on 5 November 2021 00:46:06
Authors:
Last edited:
4 October 2022 12:36:25
Categories:
Lower Extremity | Trauma | Foot | Fractures | Acute | Overuse