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We report a case of fracture of the ulnar sesamoid of the metacarpophalangeal joint of the thumb. The role of arthrography and stress X-rays in delineating the pathological anatomy of this injury is discussed.
Morton's foot syndrome is a hereditary syndrome characterized by a short first metatarsal bone, posterior displacement of the sesamoids, and hypertrophy of the second metatarsal, causing excessive weight to be borne by the second metatarsal head. This condition results in callus formation under the second metatarsal. Pain and tenderness are usually felt at the base of the first two metatarsal bones and at the head of the second. Pain (metatarsalgia) may be disabling. Conservative treatment consists of placing a flexible pad under the first metatarsal and toe to increase the range of motion and weight-bearing along the first metatarsophalangeal joint and the hallux. Surgical treatment consists of removing a small portion of bone from one or two joints to bring the toe down to the desired length. Lengthening short toes by placing a silicon implant into one of the joints is also possible.
This paper reviews 26 patients who presented with disorders of one or both sesamoids of the foot. There is a high association between long-distance running and chondromalacia or stress fractures in these bones. Thirty-eight per cent of these patients had variations in the anatomy at this articulation, including asymmetry in sesamoid size, symmetrical sesamoid enlargement, metatarsal condylar hypoplasia, and metatarsal rotational abnormalities.
Disorders of the hallux sesamoids and associated soft-tissue structures are commonly seen. With a differential diagnosis consisting of no fewer than 30 conditions, establishing an accurate diagnosis can be challenging but is important to appropriate treatment implementation. An understanding of first metatarsophalangeal joint anatomy, function, and current diagnostic technology aids the practitioner in the diagnosis and successful treatment of these often overlooked and anecdotally managed disorders.
The authors present a surgical technique for the preservation and repair of an acutely fractured sesamoid using internal fixation of the sesamoid. A case report demonstrating the technique for the open reduction and internal fixation of a fractured tibial sesamoid is presented. The authors recommend this procedure as a viable alternative to surgical excision of the tibial sesamoid. The use of the procedure as an adjunct for the surgical treatment of recalcitrant traumatic sesamoiditis is also discussed.
The mineralization of the skeleton from hatching to near maximum size in two phrynosomatid lizards, Callisaurus draconoides and Uta stansburiana, is described in detail. Observed patterns in the appearance of epiphyseal secondary centers, ossification centers, apophyseal ossifications, and calcifications, the distribution of sesamoids, and the timing of fusions, are compared and contrasted with observations of other squamates available in the literature. Overall, Callisaurus and Uta exhibit an advanced state of ossification in the hatchling relative to other squamate neonates and share a similar sequence of braincase fusions and appearance of secondary centers. Preliminary observations suggest that patterns of postnatal skeletal development are highly conserved and independent of patterns of prenatal morphogenesis, and thus a potentially rich source of character data for systematic investigations.
We report a case of acute fracture of both sesamoids of the great toe in an athlete. The fractures healed uneventfully after non-surgical treatment.
There has been little emphasis placed on the excision of accessory bones of the foot. The authors present a review of the literature and a description of a surgical procedure for excision of the hallux interphalangeal joint sesamoid using minimal incision technique. A detailed analysis of the anatomy involved is also presented. A variety of other procedures for excision of this accessory bone are reviewed.
Although there are many studies in the equine literature focused on articular diseases and the aetiology of osteoarthritis, few have concentrated on normal articular structures and how they change with age. The objective of this investigation was to study the thickness and morphology of the calcified cartilage layer of the distal metacarpus over a range of ages. A parasagittal slab of bone was sectioned from the region of sesamoid contact on the medial condyle of the metacarpi from 34 horses. The slab of bone was preserved, dehydrated and embedded, undecalcified, in methylmethacrylate and then stained with toluidine blue. Six repeatable fields of interest from the distal aspect of each metacarpus were digitised and examined to determine the morphology of the calcified cartilage layer. The thickness of the calcified cartilage, range 88-426 microm, was estimated using a method of integration. The results indicate an age-related influence on the thickness of the calcified cartilage layer, generally increased in older horses. While this finding is significant, perhaps more importantly a positional relationship was also identified, indicating that pressures endured by different regions within a joint may dictate morphological development of the tissues. This study has begun to lay the groundwork to determine whether the calcified layer of the hyaline cartilage could be involved in the development of osteoarthritis.
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The authors present a prospective intraoperative evaluation of the articular wear pattern of the first metatarsal, tibial and fibular sesamoids, and base of the proximal phalanx of 166 feet undergoing hallux valgus surgery. The collected data were compared with various clinical parameters and radiographic measurements to determine if any of these variables can predict the incidence and location of articular erosion. The incidence and predictability of the location of the articular erosion increased significantly as the patient's age ( P = .000), intermetatarsal angle 1-2 ( P = .004), hallux abductus angle ( P = .000), tibial sesamoid position ( P = .016), and proximal articular set angle ( P = .02) increased. The association of foot type (ie, digital length pattern), metatarsal protrusion distance, metatarsal head shape, and hallux abductus interphalangeus was not significant. Therefore, preoperative clinical parameters (ie, age) and radiographic measurements (ie, intermetatarsal angle 1-2, hallux abductus angle, tibial sesamoid position, and proximal articular set angle) can directly define the incidence and location of articular erosion and are helpful in the preoperative assessment of the hallux valgus deformity. In addition, nearly every first metatarsophalangeal joint evaluated had some degree of articular erosion and, in certain circumstances (ie, advanced age and increased proximal articular set angle), it was universal and extensive.
From a total of 165 foot and lower leg cadaveric specimens, 38 specimens were selected by palpation of the region of the tuberosity of the navicular for the possible presence of an accessory bone. Specimens were radiographed and dissected to reveal the presence of an accessory bone and its relationship to the tibialis posterior tendon. Nineteen of the specimens exhibited hypertrophy of the tibialis posterior tendon and 19 specimens exhibited an accessory bone. Specimens exhibiting an accessory bone were divided into two categories. In one group, the accessory bone was located in the tibialis posterior tendon prior to its division and was separated from the tuberosity by at least 3 mm. In the other group, the accessory bone was located in the main segment of the tibialis posterior tendon, connected to the tuberosity of the navicular by fibrous tissue, and, in some cases, exhibited a central cavity between the accessory bone and tuberosity. The accessory bone of specimens in the first group was considered to be a sesamoid in the tibialis posterior tendon and the accessory bone in the second group was an ossicle considered to be the os tibiale externum. Linking the os tibiale externum to the tibiale component of the primitive tetrapod foot rather than to the prehallux component eliminates the use of the term "prehallux" as an alternative name for this ossicle.
Axial sesamoid injuries were found in 4 of 18 horses with lateral condylar fractures of the metacarpus or metatarsus. The injuries appeared as axial sesamoid fractures or progressive demineralization of the axial border of one of the sesamoids. None of the horses with axial sesamoid injuries returned to performance soundness. Axial sesamoid injury appeared to be an indication of severe fetlock trauma due to condylar fracture. Such injuries appeared to indicate a poor prognosis for return to performance soundness.
Dorsal dislocations of the first metatarsophalangeal joint are classified by Jahss into two types. In Type 1, the hallux with the intact intersesamoid ligament dislocates dorsally over the metatarsal head. Such cases in the literature have been irreducible by closed manipulation. In Type 2 the hallux is dislocated dorsally with rupture of the intersesamoid ligament, resulting in wide separation of the sesamoids (Type 2A) or a transverse fracture of one or both sesamoids (Type 2B). The importance in classifying these injuries allows one to predict whether closed reduction will be successful as in Type 2. The patient reported had a fracture of the fibular sesamoid in addition to dislocation of the hallux. The clinical findings were consistent with Type 1 injury, including an intact intersesamoid ligament, but the radiographs showed, in addition to the dislocation, that there was a fracture of the fibular sesamoid. Reduction was achieved surgically through a dorsal approach. Although such injuries have been unreported previously, Type 1 injuries may be associated with a fracture of the fibular sesamoid but without rupture of intersesamoid ligament, so the injury reported is classified as Type 1A.
In this study, intermetatarsal angle (IMA) correction, functional outcome, and healing time for the proximal crescentic and proximal chevron osteotomies in moderate to severe hallux valgus deformity were prospectively compared. Seventy-five patients (97 feet) were prospectively randomized to either a proximal crescentic or proximal chevron osteotomy for the correction of moderate to severe hallux valgus deformity with associated metatarsus primus varus. Criteria for study entry included age (adult patients), IMA greater than or equal to 13 degrees, persistent symptoms despite nonoperative treatment, and minimum follow-up of 12 months. Twenty-nine patients (41 feet) in the crescentic group and 37 patients (43 feet) in the chevron group returned for follow-up at an average of 24 and 20 months, respectively. Good results were achieved with both procedures. No statistically significant differences were found with respect to correction of the IMA or to functional outcome between the two groups. Results held true irrespective of patient age, severity of disease, or bilateral involvement. A statistically significant shorter healing time of the first metatarsal was found after proximal chevron osteotomy. Other potential benefits of the chevron procedure included avoidance of dorsiflexion of the first metatarsal, tendency toward less shortening of the first metatarsal, and more medial distribution of tibial sesamoids following surgery, all of which may reduce the potential for development or persistence of transfer lesions.
A kinematic analysis of the instant centers of rotation analysis was performed on 21 metacarpophalangeal joints from 11 horses. Manual and computerized methods were used to locate the instant center of rotation on photocopies of transparent composite tracings of a series of radiographs of each joint. The instant centers of rotation of the proximal phalanx about the distal portion of the third metacarpal bone were located consistently on or near the eminence for attachment of the collateral ligaments. The instant centers of rotation of the sesamoids about the distal portion of the third metacarpal bone were consistently located near the dorsal articular margin of the distal portion of the third metacarpal bone. Rotation of the joint as it extended caused minor variation in radiographic projection. This variation in radiographic projection limited the precision of the analysis of the instant center of rotation and prevented the identification of a single instant center of rotation or an instant center of rotation pathway for the articulation of the proximal phalanx or the proximal sesamoids with the distal portion of the third metacarpal bone. The articular surface velocity vectors determined from the instant centers of rotation indicated that the joint surfaces slide on each other. The motion of the joint caused compression at the dorsal articular margins at maximal extension and thereby limited further extension. At this degree of extension, the proximal sesamoids articulated only with the proximal sesamoid-metacarpal articular surface of the distal portion of the third metacarpal bone.
The objective of this retrospective study was to provide a detailed description of the characteristics of condylar fractures represented in a population of 135 horses who sustained 145 fractures. Records and radiographic studies were examined. Fifty-nine percent of the horses were male and the majority Thoroughbreds. The distribution of fractures was 37% incomplete-nondisplaced, 30% complete-nondisplaced and 32% complete-displaced. The right front was more likely to sustain a complete-displaced fracture, whereas the left front was more likely to sustain an incomplete-nondisplaced fracture. Forelimbs (81%) and lateral condyles (85%) were more likely to be involved. Contrary to previous studies, the right forelimb was slightly more often involved than the left. Fractures tended to involve the middle portion of the condyle (59%). The mean length of all fractures was 75+/-3.8 mm. Axial fractures and medial condyle fractures tended to be longer. Fifteen percent of the fractures had definitive articular comminution. Ninety-five percent of fractures with articular comminution were associated with complete fractures. When fractures entered the middle area of the condyle, 23% had articular comminution. Eight of the fractures spiralled, all involved forelimbs. Concurrent lesions included proximal phalanx chip fractures, sesamoid fractures, sesamoiditis, proximal phalanx fractures, 'splint' bone periostitis and ligamentous injuries. The complete description of the fractures in this group of horses allows us better to define the condylar fracture, compare these fractures to previous studies and establish new data for use in defining prognosis.
A new and original sonographic technique to document the morphology of normal feet and splay feet is presented: a standard sectional plane cuts the transverse arch from the plantar side using the sesamoids of the first metatarsal bone and the head of the fifth metatarsal bone as reference points. A 5-MHz linear transducer and a rather simple custom-made platform with an integrated gel-pad are required in order to get reproducible results. The morphology of the transverse arch can be characterized by the "transverse arch index Q" as the parameter of the relative height of the transverse arch. Based on this transverse arch index Q, splay feet can be distinguished from normal feet in a statistically significant way (p < 0.01). Furthermore, grading of splay feet is possible and a documentation of rigidity/flexibility of the forefoot in splay feet; thus, the decision on whether to use conservative or operative treatment can additionally be based on sonographic documentation, and the results of surgical reconstruction of the transverse arch can be checked and documented sonographically.