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Traumatic and developmental abnormalities of the sesamoid bones of the great toe
TRAUMATIC
AND DEVELOPMENTAL
ABNORMALITIES
OF THE
SESAMOID BONES OF THE GREAT TOE* JOHN H.
POWERS, M.D.
COOPERSTOWN, N. Y.
T
HE anatomica Iocation of the metatarsa sesamoid bones of the great toe renders them particuIarIy 1iabIe to the trauma of both direct and indirect vioIence. DeveIopmentaI variations in their structure occur frequentIy and may be the seat of IocaI pain and tenderness foIIowing in juries elsewhere in the foot. The 5 cases presented here iIIustrate the importance of an accurate cIinica1 and roentgenoIogica1 diagnosis in the anaIysis of symptoms referabIe to the first metatarsophaIangea1 joint. REPORT
OF
CASES
GSE I. A. G., a white maIe, aged twentyone years, came to the hospitaI on February 6, 1932, because of tenderness beneath the bal1 of the right great toe, and pain in this area on waIking. Several days previousIy, whiIe carrying one end of a heavy refrigerator, his foot sIipped from the curb to a cement road, producing acute hyperextension of the great toe and direct trauma to the pIantar surface of the foot in the region of the first metatarsophalangeal joint. Examination disclosed IocaI tenderness beneath the head of the first metatarsa1 bone. The foot was strapped with adhesive pIaster without reIief from symptoms and ten days later roentgenoIogica1 examination reveared “an irregularity in one of the sesamoids beneath the dista1 end of the first metatarsa1, suggesting the possibiIity of fracture” (Fig. IA). A doughnut made of saddler’s felt was appIied to relieve direct pressure on the sesamoid bones. The symptoms persisted and after the Iapse of one month the patient stiI1 had pain with every step, IocaI tenderness, and pain when the great toe was dorsiflexed. A metatarsal bar was attached to the sore of the shoe. StiII no reIief was obtained and in May a pIaster boot was appIied. It was essentia1 * From the Department
for the patient to continue with his job and the plaster was worn for onIy a week, because of his diffrcuIty in getting about. A thick pad of feit was strapped beneath the arch of the foot and worn for three months. During this period the symptoms partiaIIy subsided but never entireIy abated. X-rays showed no change in the appearance of the lateral, or fibuIar, sesamoid. Operative remova of the bone was advised and refused by the patient. He continued to work reguIarIy and was not seen again unti1 October. At that time he stiI1 had occasiona miId pain when the great toe was hyperextended, and IocaI tenderness to pressure. The patient returned on January 5, 1933. Two months previously he had purchased a new pair of shoes, one size larger than he was accustomed to wear, and since then had been entirely free from symptoms. Examination stiI1 showed shght tenderness to deep palpation beneath the head of the first metatarsaI bone. X-rays discIosed some absorption of the proxima1 fragment of the fibuIar sesamoid (Fig. I B). No new bone was apparent.
Comment. This is a case of true fracture of the fibuIar sesamoid, a rare type of injury. The patient was unabIe to rest the foot compIeteIy and symptoms persisted for a Iong period of time, in spite of numerous conservative methods of treatment. CASE II. F. M., a white maIe aged thirtyfive years, came to the hospita1 on December IO, 193 I, because of persistent pain, sweIIing and tenderness foIIowing a sprained ankIe. When the injury was sustained severa days previously, the foot had been turned acuteIy in eversion. Examination discIosed local swelling and tenderness over the interna IateraI Iigament of the right ankIe. The foot was strapped in inversion with adhesive plaster. Four days Iater, the a&e was improved but the patient complained of pain beneath
of Surgery, The Mary Imogene Bassett Hospital.
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American Journal of Surgery
Powers-Sesamoid
the anterior arch. Examination reveaIed tenderness under the head of the first metatarsa1 bone. A feIt pad was appIied beneath the trans-
A
FIG. I. Case I. A. and a.
B
Bones
FEBRUARY, 1934
Normal activity was not restricted. The symptoms entirely subsided and he was discharged weII on January 20, 1932. An x-ray fiIm of the
c
D
Roentgenogramsof right foot revealing comminuted fracture of fibuIar sesamoid. c. and D. Films eleven months later show no new bone.
verse arch and the ankIe was restrapped. After an interva1 of three days the strapping was removed and the patient was discharged.
FIG. 2.
Case
foot on that date showed no change in the appearance of the sesamoid bone. One year Iater the patient came in for
IV. Anteroposterior and IateraI fiIms of both feet, showing biIatera1 deveIopmenta1 of media1 metatarso-phaIangea1 sesamoids of great toe,
One week Iater he returned to the hospita1 because of persistent tenderness beIow the dista1 end of the first metatarsa1. X-ray pIates of the foot were taken and interpreted as foIIows : “FiIms of the right foot show the mesia1 sesamoid beneath the end of the first metatarsa1 to be in two fragments, each having an irreguIar margin in the adjoining edges, and but slightly separated. This sesamoid bone has probably been fractured.” A smaI1 doughnut made of saddIer’s feIt was pIaced beneath the point of tenderness to reIieve the pressure of weight-bearing. The patient was seen at intervaIs during. the foIIowing month and the feIt pad was changed.
bipartism
observation. fina There had been no recurrence of pain or tenderness beneath the head of the first metatarsa1 and examination was negative. X-ray fiIms of the foot showed no change in the appearance of the mesia1 sesamoid which was stiI1 bipartite. No new bone was apparent. FiIms of the other foot were normaI.
Comment. There was no direct or indirect trauma to the sesamoid bone. Symptoms referabIe to the first metatarso-phalangeal joint appeared only after the normaI mechanics of the foot had been disturbed by a Sprain of the interna IateraI Iigament of the ankIe. An x-ray fiIm taken
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one year after the accident showed no change in the appearance of the mesia1 sesamoid and no new bone. In view of these
Bones were noted. The ankle was strappecl in ever&on; ice packs, rest and elevation were adviseci. Three
FIG. 3. Gas: L-. Roentgrnograms showing hiIatera1 congenital tot. Note wide separation of segments in left foot as compared
facts, it seems evident that this is a case of deveIopmenta1 division of the mediaI, or tibiaI, sesamoid and not a fracture. CASE III. S. S., a white mare, aged fortyone years, was seen on January 8, 1932, because of a “sprained ankle.” Twentv-four hours previousIi he had faIIen and turned the right
clays later
bipartism with right,
the pain
had tlisappeared
of medial sesamoid bones of great and oblique line of division in c,arh.
and the swelIing and tenderness were subsiding. The patient was aIlowed to get about \vith crutches which he shortIy discarded for a cane. At the end of a week there was no pain on waIking. An elastic bandage was appIied and the patient was discharged. Two months Iater he returned cIaiming that he had not been abIe to resume hi:; “Usual
FIG. 4.
FIG.
6.
FIG. 4. DeveIopmentaI quadripartism of media1 sesamoid. FIG. 3. Congenital division of IateraI, or fibuIar, sesamoid. DeveIopmentaI bipartism of media1 sesamoid showing two fragments of equa1 adjacent edges separated by a transverse ckft.
foot. acuteIy in inversion. Examination disclosed ecchymosis, sweIIing and tenderness over the externa1 IateraI Iigament, and pain on inversion of the foot. X-ray fiIms of the ankIe reveaIed no fracture; hypertrophic changes in the tarsus
size with
smooth
occupation, that of a butcher, because of faiIure to regain fuI1 function of the right ankle. Examination discIosed no sweIIing; motion of the ankIe was normaI. Tenderness to palpation was eIicited over the external latera
378
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Journal
of Surgery
Powers-Sesamoid
ligament, on the dorsum of the foot just anterior to the external maIIeoIus, and beneath the head of the first metatarsa1. Roentgenologi-
FIG.
7A.
FIG.
FIG. 7. [Different
Bones
FEBRUARY,
rgj
Examination discIosed sweIIing of the anteriol part of the foot and marked tenderness particularIy over the first metatarsa1 bone
7B.
FIG.
7c.
types of congenita1 division of the media1 sesamoid. A. DistaI segment smaIIer; cleft narrow and obliaue. B. Distal segment Iareer and semilunar in shaDe: cleft wide and obliaue. c. Two fragments equa1 in size, with roundid corners, and separated by narrow,AodIique cIeft.
ca1 examination of the foot showed “ apparendy a fracture of the media1 sesamoid beneath the distal end of the first metatarsa1 bone.” A fiIm of the opposite foot was normaI. In view of the fact that the patient suffered no discomfort beneath the baI1 of the foot on waIking, a protective dressing was not applied. Physiotherapeutic treatments of the ankIe were folIowed by resumption of norma activity in three weeks. On January 5, 1933, one year after the accident, the patient &II compIained of occasiona sweIIing and stiffness of the right a&e. There was no pain or tenderness beneath the head of the first metatarsa1 bone. X-ray fiIms of the foot discIosed no change in the appearance of the media1 sesamoid. The bone was bipartite; no caIIus was seen.
Comment. This case represents another instance of deveIopmenta1 division of the tibia1 sesamoid, misinterpreted as fracture, with symptoms referabIe to the anomaIy appearing incidentaIIy foIIowing a sprained ankIe. CASE IV. E. R., a white gir1, sixteen years of age, was seen March 20, 1932, because of an injury to the right foot sustained the previous evening during gymnastic exercises. The exact nature of the trauma couId not. be ascertained.
Anteroposterior and IateraI fiIms of both feet reveaIed biIatera1 deveIopmenta1 division of the media1 sesamoid bones (Fig. 2). The foot and ankIe were strapped with adhesive pIaster, temporary rest was advised, and the symptoms entireIy subsided. The patient was seen ten months Iater. FiIms of the feet at that time showed no change in the appearance of the sesamoid bones.
Comment. This case represents the incidenta1 discovery of deveIopmenta1 biIatera1 media1 sesamoids and indicates the importance of taking fiIms of each foot when making a differentia1 diagnosis of symptoms in the region of the first metatarso-phaIangea1 joint. CASE v. Mrs. A. P., a stout white woman, aged fifty-two years, was seen May I I, 1932, because of pain in the right foot, severa weeks in duration. The discomfort was gradua1 in onset. and coincident with a period during which it was necessary for the patient to be on her feet more than usuaI. Examination showed biIatera1 pes pIanus and slight diffuse sweIIing of the dorsum of the right foot. Anteroposterior and IateraI fiIms of each foot reveaIed biIatera1 division of the media1 sesamoid bones (Fig. 3).
NEX. San~r.s
The
VOL.
XXIII,
symptoms
Powers-Sesamoid
No. z
subsided
foIIowing
appro-
the fibuIar sesamoid. The size of the bones is somewhat inconstant. The median is usuaIIy the larger
priate treatment for flat feet. The roentgenoIogical examination was repeated January 5,
FIG.
FIG. 8~.
8A.
FIG. 8.’ Different types of “dumb-beII” sesamoids. of ossification between normal and biDartite bone. C. Compare with Figure 7 c.
It A.
I
1933, and discIosed no change in the appearance of the sesamoids.
Comment. This represents another case of biIatera1 deveIopmenta1 bipartism of the media1 sesamoid bones, discovered incidentaIIy and unreIated to the presenting symptoms. ANATOMICAL
Bones
CONSIDERATIONS
The metatarso-phaIangea1 sesamoids of the haIIux are a constant feature of the osseous structure of the foot. They Iie one in each tendon of the flexor brevis haIIucis just proxima1 to its insertion into the first phalanx. The median, or tibial, bone is situated directIy beneath the medial haIf of the head of the first metatarsa1 where it may be subjected frequentIy to mechanica1 trauma; the IateraI, or fibuIar, sesamoid usuaIIy extends we11 beyond the IateraI margin of this bone and assumes a relativeIy protected position in the soft tissues between the heads of the first and second metatarsaIs. This is particuIarIy true in the feet of civiIized races and may account for the infrequency of traumatic Iesions of
FIG. 8c.
is suggested that these represent intermediate stages Compare with Figure 7 A. B. Compare with Figure 7 B.
and in the aduIt varies from 12 to I 5 mm. in Iength and g to I I mm. in width. The IateraI is g to IO mm. long by 7 to g mm. wide.’ NormaIIy the bones present an oval appearance in the anteroposterior view and in profile, a semiIunar sheII. The pIantar surface of each is convex; the dorsa1 surface is concave and enters into the structure of the metatarso-phaIangea1 joint. DEVELOPMENTAL
VARIATIONS
The sesamoid bones are preformed in cartiIage and enchondraIIy ossified.2 According to Burman and Lapidus3 ossification takes pIace about the eighth or ninth year; according to Orr,l between the eIeventh and fourteenth years. IrreguIarities in ossification occur frequentIy, Ieading to the formation of doubIe sesamoids which may easiIy be mistaken for fracture. Tripartite and quadripartite bones aIso have been described. The author examined films of IOO feet taken at random from the files of the roentgenoIogica1 department of the hospita1
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of Surgery
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and found anomaIous sesamoids in 14 per cent. Fifty-one fiIms were of the right foot and showed bipartism of the medial sesamoid in 6 cases and quadripartism in I (Fig. 4). Forty-nine fiIms of the Ieft foot discIosed division of the medial sesamoid 6 times and division of the fibuIar sesamoid once onIy (Fig. 5). These figures are in accord with those of Geist4 who found congenita1 division 16 times in IOO cases, and are proportionate to those of Burman and Lapidus3 who observed division of the media1 sesamoid 72 times but of the IateraI sesamoid onIy 6 times in a series of IOOO roentgenograms. The fragments may be equa1 or unequal in size and are usuaIIy separated by a smooth Iine of cIeavage which is either at right angIes or oblique to the Iong axis of the bone (Figs. 6 and 7). In the author’s series of deveIopmenta1 anomalies the fragments were more frequentIy unequa1 and separated by an obIique Iine of division. Cases of partia1 division were seen which suggest incompIete fusion in the middIe of the bone from two periphera1 centers of ossification (Fig. 8). These are interesting to compare with the tracings shown in Figure 7 for they aIso occur with equa1 or unequa1 segments and transverse or obIique partia1 Iines of division. They represent stages in the deveIopment and ossification of these bones, which are intermediate between the normal singIe sesamoid and the less frequent bipartite bone. It is conceivabIe, however, that this “dumb-beII” appearance may be due to an oId heaIed fracture, aIthough the records of these patients reveal no history of trauma in earIy Iife. Many of the partiaIIy divided bones show an area of rarifaction between the niches, which further suggests that they are deveIopmenta1 anomaIies resuIting from incompIete ossification rather than the end-results of oId traumatic Iesions. TRAUMATIC
LESIONS
Fracture of the metatarso-phaIangea1 sesamoids of the haIIux is not common but may occur as the resuIt of either direct or
Bones
indirect violence. The former is usuaIIy due to a crushing injury of the anterior portion of the foot, a faI1 from a height, or direct trauma beneath the head of the first metatarsa1 bone. Indirect vioIence is due to sudden, acute hyperextension of the great toe. Some authors state that fracture of the sesamoid may be produced on the cadaver by acute dorsiffexion and abduction of the haIIux. The symptoms are those of pain on waIking, especiaIIy at the end of each step when the toes are in extension and the weight is thrown forward onto the baI1 of the foot, sweIIing, and IocaI tenderness. Examination reveals redness and sweIIing about the first metatarso-phaIangea1 joint, pain in this area if the great toe be extended, and Iocalized tenderness beneath the invoIved sesamoid. The roentgenogram offers the most accurate means of differentia1 diagnosis between fracture and deveIopmenta1 anomaIy. Fragments of the traumatic variety are usuaIIy irreguIar in outIine, present sharp, jagged corners and adjacent rough or serrated edges. The fragments of a congenitaIIy bipartite sesamoid are ova1 or semiIunar in shape with rounded corners and smooth opposing edges. This is not universaIIy true, however, for one occasionaIIy sees fragments of the congenita1 type which are wideIy separated from one another and present rough, irreguIar adjacent edges. In cases of fracture, a break in the cortica1 substance may be seen in the Iine of cIeavage whereas in congenita1 division the cortex is usuaIIy continued smoothIy around the periphery of each fragment. Comminution of the bone offers definite evidence of fracture. A radiogram of the opposite foot may be of great vaIue in reaching a differentia1 diagnosis. Freiberg5 has reported a series of patients with symptoms referabIe to the first metatarso-phaIangea1 joint, no history of trauma, and roentgenoIogica1 evidence of division of the media1 sesamoid bone. He states that if the cIeft be congenita1 in type, the symptoms are due to damage of
NEW
SI.RII.S
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Powers-Sesamoid
the fibers which connect the two segments, and concIudes that a11 symptoms are, therefore, traumatic in origin, regardIess of whether the division of the sesamoid be due to fracture or developmenta anomaIy. TREATMENT
An accurate differentia1 diagnosis between traumatic and deveIopmenta1 anomaIies is of considerabIe academic interest and offers much assistance in prognosis. RegardIess of the etioIogy, however, the treatment is the same, whether the Iesion be primariIy traumatic or developmenta in origin. Conservative measures offering protection, support, and reIief from the strain of weight-bearing are indicated. This may be achieved by a doughnut made from saddIer’s feIt and pIaced around the invoIved bone, a thick pad of feIt strapped to the pIantar surface of the foot or a metatarsa1 bar affIxed to the soIe of the shoe just proximaI to the anterior arch. One of these methods is usuaIIy adequate to reIieve symptoms due to a deveIopmenta1 anomaIy. True fractures of the sesamoid are much more resistant to treatment and the prognosis shouId be guarded, for the symptoms are apt to persist for a Iong period of time. Most authors recommend the appIication of a pIaster boot or excision of the fragmented bone. SUMMARY
AND
CONCLUSION
One case of fracture of the fibuIar sesamoid of the haIIux and 4 cases of deveIopmenta1 anomalies of the tibiaI, in 2 of which
Bones
American Journ;ll ol Surgcrg
321
the Iesion is biIatera1, have been described in detai1. One hundred roentgenograms of feet, examined to determine the frequency of congenita1 variations in the structure of the sesamoids, discIosed 13 cases of bipartism and I case of quadripartism. SeveraI reproductions of “ dumb-be11 ” sesamoids have been presented as examples of incomplete deveIopment, intermediate between the normaI singIe sesamoid and the congenita1 bipartite bone. Fracture of the metatarso-phaIangea1 sesamoids of the great toe is not common but may resuIt from either direct or indirect vioIence. DeveIopmentaI anomalies occur frequentIy, due to irreguIarities of ossification, and may readiIy be confused with traumatic Iesions. The media1 sesamoid is more commonIy invoIved than the IateraI. Symptoms of fracture may be caused by sIight trauma to a bone which is congenitaIIy divided. The differential diagnosis is based IargeIy upon the type and severity of the trauma, and the appearance of the sesamoid in the roentgenogram. Conservative treatment is indicated, whether the symptoms be due to fracture or deveIopmenta1 anomaIies. The prognosis for true fractures shouId be guarded. REFERENCES
of great toe sesamoids. Ann. Surg., 67: 609, 1918. KBHLER. Rijntgenology. N. Y., Wood, 1929, p. 22. BURMAN, M. S., and LAPIDUS, P. W. The functional disturbances caused by the inconstant bones and sesamoids of the foot. Arch. Surg., 22: 936, 1931. GEIST, E. S. Supernumerary bones of the feet: a roentgen study of the feet of one hundred normal individuals. Am. J. Ortbop. Surg., I 2: 403, 19141915. FREIBERG, A. H. Injuries to the sesamoid bones of the great toe. J. Ortbop. Surg., 2: 453. r92o.
I. ORR, T. G. Fracture
2. 3.
4.
5.
AND DEVELOPMENTAL
ABNORMALITIES
OF THE
SESAMOID BONES OF THE GREAT TOE* JOHN H.
POWERS, M.D.
COOPERSTOWN, N. Y.
T
HE anatomica Iocation of the metatarsa sesamoid bones of the great toe renders them particuIarIy 1iabIe to the trauma of both direct and indirect vioIence. DeveIopmentaI variations in their structure occur frequentIy and may be the seat of IocaI pain and tenderness foIIowing in juries elsewhere in the foot. The 5 cases presented here iIIustrate the importance of an accurate cIinica1 and roentgenoIogica1 diagnosis in the anaIysis of symptoms referabIe to the first metatarsophaIangea1 joint. REPORT
OF
CASES
GSE I. A. G., a white maIe, aged twentyone years, came to the hospitaI on February 6, 1932, because of tenderness beneath the bal1 of the right great toe, and pain in this area on waIking. Several days previousIy, whiIe carrying one end of a heavy refrigerator, his foot sIipped from the curb to a cement road, producing acute hyperextension of the great toe and direct trauma to the pIantar surface of the foot in the region of the first metatarsophalangeal joint. Examination disclosed IocaI tenderness beneath the head of the first metatarsa1 bone. The foot was strapped with adhesive pIaster without reIief from symptoms and ten days later roentgenoIogica1 examination reveared “an irregularity in one of the sesamoids beneath the dista1 end of the first metatarsa1, suggesting the possibiIity of fracture” (Fig. IA). A doughnut made of saddler’s felt was appIied to relieve direct pressure on the sesamoid bones. The symptoms persisted and after the Iapse of one month the patient stiI1 had pain with every step, IocaI tenderness, and pain when the great toe was dorsiflexed. A metatarsal bar was attached to the sore of the shoe. StiII no reIief was obtained and in May a pIaster boot was appIied. It was essentia1 * From the Department
for the patient to continue with his job and the plaster was worn for onIy a week, because of his diffrcuIty in getting about. A thick pad of feit was strapped beneath the arch of the foot and worn for three months. During this period the symptoms partiaIIy subsided but never entireIy abated. X-rays showed no change in the appearance of the lateral, or fibuIar, sesamoid. Operative remova of the bone was advised and refused by the patient. He continued to work reguIarIy and was not seen again unti1 October. At that time he stiI1 had occasiona miId pain when the great toe was hyperextended, and IocaI tenderness to pressure. The patient returned on January 5, 1933. Two months previously he had purchased a new pair of shoes, one size larger than he was accustomed to wear, and since then had been entirely free from symptoms. Examination stiI1 showed shght tenderness to deep palpation beneath the head of the first metatarsaI bone. X-rays discIosed some absorption of the proxima1 fragment of the fibuIar sesamoid (Fig. I B). No new bone was apparent.
Comment. This is a case of true fracture of the fibuIar sesamoid, a rare type of injury. The patient was unabIe to rest the foot compIeteIy and symptoms persisted for a Iong period of time, in spite of numerous conservative methods of treatment. CASE II. F. M., a white maIe aged thirtyfive years, came to the hospita1 on December IO, 193 I, because of persistent pain, sweIIing and tenderness foIIowing a sprained ankIe. When the injury was sustained severa days previously, the foot had been turned acuteIy in eversion. Examination discIosed local swelling and tenderness over the interna IateraI Iigament of the right ankIe. The foot was strapped in inversion with adhesive plaster. Four days Iater, the a&e was improved but the patient complained of pain beneath
of Surgery, The Mary Imogene Bassett Hospital.
3’4
316
American Journal of Surgery
Powers-Sesamoid
the anterior arch. Examination reveaIed tenderness under the head of the first metatarsa1 bone. A feIt pad was appIied beneath the trans-
A
FIG. I. Case I. A. and a.
B
Bones
FEBRUARY, 1934
Normal activity was not restricted. The symptoms entirely subsided and he was discharged weII on January 20, 1932. An x-ray fiIm of the
c
D
Roentgenogramsof right foot revealing comminuted fracture of fibuIar sesamoid. c. and D. Films eleven months later show no new bone.
verse arch and the ankIe was restrapped. After an interva1 of three days the strapping was removed and the patient was discharged.
FIG. 2.
Case
foot on that date showed no change in the appearance of the sesamoid bone. One year Iater the patient came in for
IV. Anteroposterior and IateraI fiIms of both feet, showing biIatera1 deveIopmenta1 of media1 metatarso-phaIangea1 sesamoids of great toe,
One week Iater he returned to the hospita1 because of persistent tenderness beIow the dista1 end of the first metatarsa1. X-ray pIates of the foot were taken and interpreted as foIIows : “FiIms of the right foot show the mesia1 sesamoid beneath the end of the first metatarsa1 to be in two fragments, each having an irreguIar margin in the adjoining edges, and but slightly separated. This sesamoid bone has probably been fractured.” A smaI1 doughnut made of saddIer’s feIt was pIaced beneath the point of tenderness to reIieve the pressure of weight-bearing. The patient was seen at intervaIs during. the foIIowing month and the feIt pad was changed.
bipartism
observation. fina There had been no recurrence of pain or tenderness beneath the head of the first metatarsa1 and examination was negative. X-ray fiIms of the foot showed no change in the appearance of the mesia1 sesamoid which was stiI1 bipartite. No new bone was apparent. FiIms of the other foot were normaI.
Comment. There was no direct or indirect trauma to the sesamoid bone. Symptoms referabIe to the first metatarso-phalangeal joint appeared only after the normaI mechanics of the foot had been disturbed by a Sprain of the interna IateraI Iigament of the ankIe. An x-ray fiIm taken
New SEHIES VOL. XXIII,
No.
2
Powers-Sesamoid
one year after the accident showed no change in the appearance of the mesia1 sesamoid and no new bone. In view of these
Bones were noted. The ankle was strappecl in ever&on; ice packs, rest and elevation were adviseci. Three
FIG. 3. Gas: L-. Roentgrnograms showing hiIatera1 congenital tot. Note wide separation of segments in left foot as compared
facts, it seems evident that this is a case of deveIopmenta1 division of the mediaI, or tibiaI, sesamoid and not a fracture. CASE III. S. S., a white mare, aged fortyone years, was seen on January 8, 1932, because of a “sprained ankle.” Twentv-four hours previousIi he had faIIen and turned the right
clays later
bipartism with right,
the pain
had tlisappeared
of medial sesamoid bones of great and oblique line of division in c,arh.
and the swelIing and tenderness were subsiding. The patient was aIlowed to get about \vith crutches which he shortIy discarded for a cane. At the end of a week there was no pain on waIking. An elastic bandage was appIied and the patient was discharged. Two months Iater he returned cIaiming that he had not been abIe to resume hi:; “Usual
FIG. 4.
FIG.
6.
FIG. 4. DeveIopmentaI quadripartism of media1 sesamoid. FIG. 3. Congenital division of IateraI, or fibuIar, sesamoid. DeveIopmentaI bipartism of media1 sesamoid showing two fragments of equa1 adjacent edges separated by a transverse ckft.
foot. acuteIy in inversion. Examination disclosed ecchymosis, sweIIing and tenderness over the externa1 IateraI Iigament, and pain on inversion of the foot. X-ray fiIms of the ankIe reveaIed no fracture; hypertrophic changes in the tarsus
size with
smooth
occupation, that of a butcher, because of faiIure to regain fuI1 function of the right ankle. Examination discIosed no sweIIing; motion of the ankIe was normaI. Tenderness to palpation was eIicited over the external latera
378
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Journal
of Surgery
Powers-Sesamoid
ligament, on the dorsum of the foot just anterior to the external maIIeoIus, and beneath the head of the first metatarsa1. Roentgenologi-
FIG.
7A.
FIG.
FIG. 7. [Different
Bones
FEBRUARY,
rgj
Examination discIosed sweIIing of the anteriol part of the foot and marked tenderness particularIy over the first metatarsa1 bone
7B.
FIG.
7c.
types of congenita1 division of the media1 sesamoid. A. DistaI segment smaIIer; cleft narrow and obliaue. B. Distal segment Iareer and semilunar in shaDe: cleft wide and obliaue. c. Two fragments equa1 in size, with roundid corners, and separated by narrow,AodIique cIeft.
ca1 examination of the foot showed “ apparendy a fracture of the media1 sesamoid beneath the distal end of the first metatarsa1 bone.” A fiIm of the opposite foot was normaI. In view of the fact that the patient suffered no discomfort beneath the baI1 of the foot on waIking, a protective dressing was not applied. Physiotherapeutic treatments of the ankIe were folIowed by resumption of norma activity in three weeks. On January 5, 1933, one year after the accident, the patient &II compIained of occasiona sweIIing and stiffness of the right a&e. There was no pain or tenderness beneath the head of the first metatarsa1 bone. X-ray fiIms of the foot discIosed no change in the appearance of the media1 sesamoid. The bone was bipartite; no caIIus was seen.
Comment. This case represents another instance of deveIopmenta1 division of the tibia1 sesamoid, misinterpreted as fracture, with symptoms referabIe to the anomaIy appearing incidentaIIy foIIowing a sprained ankIe. CASE IV. E. R., a white gir1, sixteen years of age, was seen March 20, 1932, because of an injury to the right foot sustained the previous evening during gymnastic exercises. The exact nature of the trauma couId not. be ascertained.
Anteroposterior and IateraI fiIms of both feet reveaIed biIatera1 deveIopmenta1 division of the media1 sesamoid bones (Fig. 2). The foot and ankIe were strapped with adhesive pIaster, temporary rest was advised, and the symptoms entireIy subsided. The patient was seen ten months Iater. FiIms of the feet at that time showed no change in the appearance of the sesamoid bones.
Comment. This case represents the incidenta1 discovery of deveIopmenta1 biIatera1 media1 sesamoids and indicates the importance of taking fiIms of each foot when making a differentia1 diagnosis of symptoms in the region of the first metatarso-phaIangea1 joint. CASE v. Mrs. A. P., a stout white woman, aged fifty-two years, was seen May I I, 1932, because of pain in the right foot, severa weeks in duration. The discomfort was gradua1 in onset. and coincident with a period during which it was necessary for the patient to be on her feet more than usuaI. Examination showed biIatera1 pes pIanus and slight diffuse sweIIing of the dorsum of the right foot. Anteroposterior and IateraI fiIms of each foot reveaIed biIatera1 division of the media1 sesamoid bones (Fig. 3).
NEX. San~r.s
The
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subsided
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the fibuIar sesamoid. The size of the bones is somewhat inconstant. The median is usuaIIy the larger
priate treatment for flat feet. The roentgenoIogical examination was repeated January 5,
FIG.
FIG. 8~.
8A.
FIG. 8.’ Different types of “dumb-beII” sesamoids. of ossification between normal and biDartite bone. C. Compare with Figure 7 c.
It A.
I
1933, and discIosed no change in the appearance of the sesamoids.
Comment. This represents another case of biIatera1 deveIopmenta1 bipartism of the media1 sesamoid bones, discovered incidentaIIy and unreIated to the presenting symptoms. ANATOMICAL
Bones
CONSIDERATIONS
The metatarso-phaIangea1 sesamoids of the haIIux are a constant feature of the osseous structure of the foot. They Iie one in each tendon of the flexor brevis haIIucis just proxima1 to its insertion into the first phalanx. The median, or tibial, bone is situated directIy beneath the medial haIf of the head of the first metatarsa1 where it may be subjected frequentIy to mechanica1 trauma; the IateraI, or fibuIar, sesamoid usuaIIy extends we11 beyond the IateraI margin of this bone and assumes a relativeIy protected position in the soft tissues between the heads of the first and second metatarsaIs. This is particuIarIy true in the feet of civiIized races and may account for the infrequency of traumatic Iesions of
FIG. 8c.
is suggested that these represent intermediate stages Compare with Figure 7 A. B. Compare with Figure 7 B.
and in the aduIt varies from 12 to I 5 mm. in Iength and g to I I mm. in width. The IateraI is g to IO mm. long by 7 to g mm. wide.’ NormaIIy the bones present an oval appearance in the anteroposterior view and in profile, a semiIunar sheII. The pIantar surface of each is convex; the dorsa1 surface is concave and enters into the structure of the metatarso-phaIangea1 joint. DEVELOPMENTAL
VARIATIONS
The sesamoid bones are preformed in cartiIage and enchondraIIy ossified.2 According to Burman and Lapidus3 ossification takes pIace about the eighth or ninth year; according to Orr,l between the eIeventh and fourteenth years. IrreguIarities in ossification occur frequentIy, Ieading to the formation of doubIe sesamoids which may easiIy be mistaken for fracture. Tripartite and quadripartite bones aIso have been described. The author examined films of IOO feet taken at random from the files of the roentgenoIogica1 department of the hospita1
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and found anomaIous sesamoids in 14 per cent. Fifty-one fiIms were of the right foot and showed bipartism of the medial sesamoid in 6 cases and quadripartism in I (Fig. 4). Forty-nine fiIms of the Ieft foot discIosed division of the medial sesamoid 6 times and division of the fibuIar sesamoid once onIy (Fig. 5). These figures are in accord with those of Geist4 who found congenita1 division 16 times in IOO cases, and are proportionate to those of Burman and Lapidus3 who observed division of the media1 sesamoid 72 times but of the IateraI sesamoid onIy 6 times in a series of IOOO roentgenograms. The fragments may be equa1 or unequal in size and are usuaIIy separated by a smooth Iine of cIeavage which is either at right angIes or oblique to the Iong axis of the bone (Figs. 6 and 7). In the author’s series of deveIopmenta1 anomalies the fragments were more frequentIy unequa1 and separated by an obIique Iine of division. Cases of partia1 division were seen which suggest incompIete fusion in the middIe of the bone from two periphera1 centers of ossification (Fig. 8). These are interesting to compare with the tracings shown in Figure 7 for they aIso occur with equa1 or unequa1 segments and transverse or obIique partia1 Iines of division. They represent stages in the deveIopment and ossification of these bones, which are intermediate between the normal singIe sesamoid and the less frequent bipartite bone. It is conceivabIe, however, that this “dumb-beII” appearance may be due to an oId heaIed fracture, aIthough the records of these patients reveal no history of trauma in earIy Iife. Many of the partiaIIy divided bones show an area of rarifaction between the niches, which further suggests that they are deveIopmenta1 anomaIies resuIting from incompIete ossification rather than the end-results of oId traumatic Iesions. TRAUMATIC
LESIONS
Fracture of the metatarso-phaIangea1 sesamoids of the haIIux is not common but may occur as the resuIt of either direct or
Bones
indirect violence. The former is usuaIIy due to a crushing injury of the anterior portion of the foot, a faI1 from a height, or direct trauma beneath the head of the first metatarsa1 bone. Indirect vioIence is due to sudden, acute hyperextension of the great toe. Some authors state that fracture of the sesamoid may be produced on the cadaver by acute dorsiffexion and abduction of the haIIux. The symptoms are those of pain on waIking, especiaIIy at the end of each step when the toes are in extension and the weight is thrown forward onto the baI1 of the foot, sweIIing, and IocaI tenderness. Examination reveals redness and sweIIing about the first metatarso-phaIangea1 joint, pain in this area if the great toe be extended, and Iocalized tenderness beneath the invoIved sesamoid. The roentgenogram offers the most accurate means of differentia1 diagnosis between fracture and deveIopmenta1 anomaIy. Fragments of the traumatic variety are usuaIIy irreguIar in outIine, present sharp, jagged corners and adjacent rough or serrated edges. The fragments of a congenitaIIy bipartite sesamoid are ova1 or semiIunar in shape with rounded corners and smooth opposing edges. This is not universaIIy true, however, for one occasionaIIy sees fragments of the congenita1 type which are wideIy separated from one another and present rough, irreguIar adjacent edges. In cases of fracture, a break in the cortica1 substance may be seen in the Iine of cIeavage whereas in congenita1 division the cortex is usuaIIy continued smoothIy around the periphery of each fragment. Comminution of the bone offers definite evidence of fracture. A radiogram of the opposite foot may be of great vaIue in reaching a differentia1 diagnosis. Freiberg5 has reported a series of patients with symptoms referabIe to the first metatarso-phaIangea1 joint, no history of trauma, and roentgenoIogica1 evidence of division of the media1 sesamoid bone. He states that if the cIeft be congenita1 in type, the symptoms are due to damage of
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the fibers which connect the two segments, and concIudes that a11 symptoms are, therefore, traumatic in origin, regardIess of whether the division of the sesamoid be due to fracture or developmenta anomaIy. TREATMENT
An accurate differentia1 diagnosis between traumatic and deveIopmenta1 anomaIies is of considerabIe academic interest and offers much assistance in prognosis. RegardIess of the etioIogy, however, the treatment is the same, whether the Iesion be primariIy traumatic or developmenta in origin. Conservative measures offering protection, support, and reIief from the strain of weight-bearing are indicated. This may be achieved by a doughnut made from saddIer’s feIt and pIaced around the invoIved bone, a thick pad of feIt strapped to the pIantar surface of the foot or a metatarsa1 bar affIxed to the soIe of the shoe just proximaI to the anterior arch. One of these methods is usuaIIy adequate to reIieve symptoms due to a deveIopmenta1 anomaIy. True fractures of the sesamoid are much more resistant to treatment and the prognosis shouId be guarded, for the symptoms are apt to persist for a Iong period of time. Most authors recommend the appIication of a pIaster boot or excision of the fragmented bone. SUMMARY
AND
CONCLUSION
One case of fracture of the fibuIar sesamoid of the haIIux and 4 cases of deveIopmenta1 anomalies of the tibiaI, in 2 of which
Bones
American Journ;ll ol Surgcrg
321
the Iesion is biIatera1, have been described in detai1. One hundred roentgenograms of feet, examined to determine the frequency of congenita1 variations in the structure of the sesamoids, discIosed 13 cases of bipartism and I case of quadripartism. SeveraI reproductions of “ dumb-be11 ” sesamoids have been presented as examples of incomplete deveIopment, intermediate between the normaI singIe sesamoid and the congenita1 bipartite bone. Fracture of the metatarso-phaIangea1 sesamoids of the great toe is not common but may resuIt from either direct or indirect vioIence. DeveIopmentaI anomalies occur frequentIy, due to irreguIarities of ossification, and may readiIy be confused with traumatic Iesions. The media1 sesamoid is more commonIy invoIved than the IateraI. Symptoms of fracture may be caused by sIight trauma to a bone which is congenitaIIy divided. The differential diagnosis is based IargeIy upon the type and severity of the trauma, and the appearance of the sesamoid in the roentgenogram. Conservative treatment is indicated, whether the symptoms be due to fracture or deveIopmenta1 anomaIies. The prognosis for true fractures shouId be guarded. REFERENCES
of great toe sesamoids. Ann. Surg., 67: 609, 1918. KBHLER. Rijntgenology. N. Y., Wood, 1929, p. 22. BURMAN, M. S., and LAPIDUS, P. W. The functional disturbances caused by the inconstant bones and sesamoids of the foot. Arch. Surg., 22: 936, 1931. GEIST, E. S. Supernumerary bones of the feet: a roentgen study of the feet of one hundred normal individuals. Am. J. Ortbop. Surg., I 2: 403, 19141915. FREIBERG, A. H. Injuries to the sesamoid bones of the great toe. J. Ortbop. Surg., 2: 453. r92o.
I. ORR, T. G. Fracture
2. 3.
4.
5.