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Trauma to the sesamoid bones of the thumb
TRAUMA
TO THE SESAMOID BONES OF THE THUMB GEO. BALLANTYNE REITZ, M.D. Attending Surgeon, St. John’s Hospital BROOKLYN,
I
to the sesamoid bone of the hand may produce marked disabiIity and produce a cIinica1 entity, the true nature of which is frequentIy overIooked. The sesamoid bones of the hand are two very smaI1 noduIes which Iie in the tendons of insertion of the flexor poIIicis brevis and abductor poIIicis. They are bIended with the palmar Iigament of the metacarpophaIangea1 joint and pIay against the paImar surface of the head of the metacarpa bone. Because of their anatomica position they are subjected to certain trauma, both direct and indirect and cause a very painfuI condition in the hand. As they Iie in the tendon to the thumb and over the head of metacarpa1 number one, any force appIied to that area, either acuteIy directed or by intermittent occupationa1 irritation, may be the cause of inflammation of these bones, & condition which is not aIways thought of. The two cases reported here came to my attention within one month and show injury to these bones, one by direct force and the other as a resuIt of chronic occupationa1 irritation. NJURY
CASE
REPORTS
CASE I. A. G., a maIe, thirty-five years of age, gave no history of previous accident to either hand. The patient stated that on June I, 1945, whiIe driIIing a piece of bronze, the drill got stuck in the hoIe and the piece of materiaI was whirIed around and hit the paImar surface of the Ieft hand over the first metacarpophaIangea1 articuIation. There was considerabIe pain and sweIIing over the site of injury. Pain continued and was accentuated each time anything was grasped by the hand or if any pressure was made directIy over the injured part of the hand. X-ray of the bones of the thumb in anteroposterior, IateraI and oblique
NEW
YORK
pIanes was negative for bone or joint disorder. Examination of the hand reveaIed neither limitation of motion nor any acquired or congenita1 deformities of the fingers. There were no sweIIings nor any signs of inllammation. The first metacarpa1 bone examined by dorsa1 and paImar routes showed no tenderness nor sweiling aIong the entire Iength. There was point tenderness on the palmar surface over the dista1 head of metacarpa1 number one. This could be eIicited by direct pressure which was more acute if the tendon and sesamoid were grasped between the examining index finger and thumb. This patient was admitted to the hospital and operated upon. Under pentotha1 sodium anesthesia, with tourniquet applied, an incision was made on the paImar surface of the hand, just beIow the crease of the metacarpophaIangeal articuIation of the thumb. The incision was through skin only; a11 other deeper dissection was done in, the pIane of the tendons and other important structures. The tendons were retracted; the sesamoid bone was exposed and removed. The deeper structures were reconstructed with No. ooo pIain catgut. The skin was brought together with black siIk. A pressure dressing was appIied and the hand immobiIized. The usual two weeks’ immobiIization foIlowed, and then active and passive motion with hot soaks was started. The pathoIogica1 report foIIows: Gross: The specimen consists of irregular piece of tissue 1.7 by 0.3 cm. One portion is grayish white and caIcified. The adjacent portion is pinkish gray, pIiabIe and soft. Microscopic: One portion of the tissue is composed of trabeculae of cancellous bone. Compact fibrous tissue is attached to the margins. There is moderate hyalinization. CASE II. L. C. a femaIe, forty-seven years of age, had had no previous injury to her hands. Her work consisted of holding a piece of work in her Ieft hand and putting insuIation into this structure. It was necessary to grasp the apparatus tightIy in her Ieft hand and exert considerabIe pressure with the right hand.
* From the Hand Clinic, St. John’s Hospital,
284
Brooklyn,
N. Y.
VOL.LXXII.NO.~
Reitz-Trauma
After five months at this work she complained of pain in the palm of the Ieft hand over the base of thumb at the metacarpophaIangea1 articmation. X-rays taken in the three planes were negative. Examination of the hand showed no arthritic changes, no acquired nor congenital deformities, no swellings nor signs of inffammation and no loss of motion of any of the fingers. The only positive finding was tenderness over the sesamoid bones, elicited by direct pressure and also by lateral pressure, using the examining index finger and thumb. This case was admitted to the hospital for operation and the same procedure was foIIowed as on the previous case.
to Thumb
American Journd of Surgery
285
The pathoIogica1 report foIIows: Gross: The specimen consists of a piece of bone 0.4 cm. in diameter which is irreguIar and covered by a scant amount of reddish gray fibrous and muscular tissue. Microscopic: The specimen is composed of coarse trabecuIae bone with scattered irregular marrow spaces. Osteocytes are poorIy defined. Dense, caIiginous fibrous tissue is fused with the margins. There is a foca1 osteobIastic activity. Fibroblasts of ovoid and fusiform types are scattered through the intersticis. On January 10, 1946, hnal follow-up of these cases showed both of them to be symptom free. There was no pain, nor disabiIity and they had returned to their usua1 work.
AMPUTATION at the wrist should be pIanned, if possible, so as to save the thumb and a finger or other portion of the hand against which the thumb may be apposed. Amputation at the wrist prevents the proper fitting of an artificia1 hand and wrist mechanism without undue length, and should be avoided. From “PrincipIes and Practice of Surgery” by W. Wayne Babcock (Lea & Febiger).
TO THE SESAMOID BONES OF THE THUMB GEO. BALLANTYNE REITZ, M.D. Attending Surgeon, St. John’s Hospital BROOKLYN,
I
to the sesamoid bone of the hand may produce marked disabiIity and produce a cIinica1 entity, the true nature of which is frequentIy overIooked. The sesamoid bones of the hand are two very smaI1 noduIes which Iie in the tendons of insertion of the flexor poIIicis brevis and abductor poIIicis. They are bIended with the palmar Iigament of the metacarpophaIangea1 joint and pIay against the paImar surface of the head of the metacarpa bone. Because of their anatomica position they are subjected to certain trauma, both direct and indirect and cause a very painfuI condition in the hand. As they Iie in the tendon to the thumb and over the head of metacarpa1 number one, any force appIied to that area, either acuteIy directed or by intermittent occupationa1 irritation, may be the cause of inflammation of these bones, & condition which is not aIways thought of. The two cases reported here came to my attention within one month and show injury to these bones, one by direct force and the other as a resuIt of chronic occupationa1 irritation. NJURY
CASE
REPORTS
CASE I. A. G., a maIe, thirty-five years of age, gave no history of previous accident to either hand. The patient stated that on June I, 1945, whiIe driIIing a piece of bronze, the drill got stuck in the hoIe and the piece of materiaI was whirIed around and hit the paImar surface of the Ieft hand over the first metacarpophaIangea1 articuIation. There was considerabIe pain and sweIIing over the site of injury. Pain continued and was accentuated each time anything was grasped by the hand or if any pressure was made directIy over the injured part of the hand. X-ray of the bones of the thumb in anteroposterior, IateraI and oblique
NEW
YORK
pIanes was negative for bone or joint disorder. Examination of the hand reveaIed neither limitation of motion nor any acquired or congenita1 deformities of the fingers. There were no sweIIings nor any signs of inllammation. The first metacarpa1 bone examined by dorsa1 and paImar routes showed no tenderness nor sweiling aIong the entire Iength. There was point tenderness on the palmar surface over the dista1 head of metacarpa1 number one. This could be eIicited by direct pressure which was more acute if the tendon and sesamoid were grasped between the examining index finger and thumb. This patient was admitted to the hospital and operated upon. Under pentotha1 sodium anesthesia, with tourniquet applied, an incision was made on the paImar surface of the hand, just beIow the crease of the metacarpophaIangeal articuIation of the thumb. The incision was through skin only; a11 other deeper dissection was done in, the pIane of the tendons and other important structures. The tendons were retracted; the sesamoid bone was exposed and removed. The deeper structures were reconstructed with No. ooo pIain catgut. The skin was brought together with black siIk. A pressure dressing was appIied and the hand immobiIized. The usual two weeks’ immobiIization foIlowed, and then active and passive motion with hot soaks was started. The pathoIogica1 report foIIows: Gross: The specimen consists of irregular piece of tissue 1.7 by 0.3 cm. One portion is grayish white and caIcified. The adjacent portion is pinkish gray, pIiabIe and soft. Microscopic: One portion of the tissue is composed of trabeculae of cancellous bone. Compact fibrous tissue is attached to the margins. There is moderate hyalinization. CASE II. L. C. a femaIe, forty-seven years of age, had had no previous injury to her hands. Her work consisted of holding a piece of work in her Ieft hand and putting insuIation into this structure. It was necessary to grasp the apparatus tightIy in her Ieft hand and exert considerabIe pressure with the right hand.
* From the Hand Clinic, St. John’s Hospital,
284
Brooklyn,
N. Y.
VOL.LXXII.NO.~
Reitz-Trauma
After five months at this work she complained of pain in the palm of the Ieft hand over the base of thumb at the metacarpophaIangea1 articmation. X-rays taken in the three planes were negative. Examination of the hand showed no arthritic changes, no acquired nor congenital deformities, no swellings nor signs of inffammation and no loss of motion of any of the fingers. The only positive finding was tenderness over the sesamoid bones, elicited by direct pressure and also by lateral pressure, using the examining index finger and thumb. This case was admitted to the hospital for operation and the same procedure was foIIowed as on the previous case.
to Thumb
American Journd of Surgery
285
The pathoIogica1 report foIIows: Gross: The specimen consists of a piece of bone 0.4 cm. in diameter which is irreguIar and covered by a scant amount of reddish gray fibrous and muscular tissue. Microscopic: The specimen is composed of coarse trabecuIae bone with scattered irregular marrow spaces. Osteocytes are poorIy defined. Dense, caIiginous fibrous tissue is fused with the margins. There is a foca1 osteobIastic activity. Fibroblasts of ovoid and fusiform types are scattered through the intersticis. On January 10, 1946, hnal follow-up of these cases showed both of them to be symptom free. There was no pain, nor disabiIity and they had returned to their usua1 work.
AMPUTATION at the wrist should be pIanned, if possible, so as to save the thumb and a finger or other portion of the hand against which the thumb may be apposed. Amputation at the wrist prevents the proper fitting of an artificia1 hand and wrist mechanism without undue length, and should be avoided. From “PrincipIes and Practice of Surgery” by W. Wayne Babcock (Lea & Febiger).