Orthotic treatment of sesamoid fx

[rom3o]

In your opinion what is the typical orthotic treatment of a sesamoid fx?

In my mind there are two options: morton's extension vs. dancer pads

After the pt is dx with the fx, the doc usually seems to put them in a CAM walker (limit flexion) f/u for FOs.
So, a Morton's extension would seem like the next best option, except after I think about it, you really aren't offloading the site, just keep the ray extended.

If you do a dancer pad, you are putting the toe in slight flexion, relieving the first MPJ but the patient is still flexing the foot during toe off. Stiff-soled shoes perhaps?

Then I've thought about M.E. + dancer pad. Aren't these contradictory though? M.E. is providing extension while the pad is creating flexion.

Thoughts?

Note: I am not a MD, DPM, or pod student.

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[Feli]

CAM walker with Dancer pad if they're compliant... cast if not so compliant. Maybe 3-4wks.

Eventually Dancer pad and/or turf toe taping in slight flexion for another 2-4wks when they go back to stiff soled shoes... probably a post-op velcro shoe or maybe just good boot-type of minimally flexible sole. You could then offer a sesamoidectomy down the line if painful nonunion/malunion or AVN develops.

Perhaps circlage suture in the acute injury period if it were a real high demand athletic pt and every day counted (pro or high level NCAA player/recruit who was in/nearing competitive season).

...I had this injury in the beginning of my 2nd yr in pod school. For something that sounds minor, ir's sure not fun to walk on.

 

[krabmas]

CAM walker with Dancer pad if they're compliant... cast if not so compliant. Maybe 3-4wks.

Eventually Dancer pad and/or turf toe taping in slight flexion for another 2-4wks when they go back to stiff soled shoes... probably a post-op velcro shoe or maybe just good boot-type of minimally flexible sole. You could then offer a sesamoidectomy down the line if painful nonunion/malunion or AVN develops.

Perhaps circlage suture in the acute injury period if it were a real high demand athletic pt and every day counted (pro or high level NCAA player/recruit who was in/nearing competitive season).

...I had this injury in the beginning of my 2nd yr in pod school. For something that sounds minor, ir's sure not fun to walk on.

There is an article in Foot and Ankle Clinics (The Hallus) Mar 2009 about sesamoid pathology. They basically agree with Feli except the circlage wire part. If you did circlage wire the pt would then be walking on the circlage wire which would be extremely painful or if the wire was placed circumfrencially in the transverse plane the sesamoid would then be devoid a blood supply due to the location of the vessels all being lateral and medial to the sesamoids.

The article mentioned above discusses ORIF with screws if in a high demand pt or non-union developes after conservative treatment. Their conservative treatment includes hallux spica splint/ cast prior to CAM boot and WB.

 

[Feli]

...They basically agree with Feli except the circlage wire part. If you did circlage wire the pt would then be walking on the circlage wire ...

That's why it's circlage suture and not wire

I haven't seen it done, but Myerson text/articles and some other authors I've read suggest it. Makes sense to me as an alternate option to sesamoidectomy. Screws seem darn near impossible to me just based on the peanut size... you could maybe try a threaded k-wire, but those are so fragile at the small sizes?

 

[krabmas]

That's why it's circlage suture and not wire

I haven't seen it done, but Myerson text/articles and some other authors I've read suggest it. Makes sense to me as an alternate option to sesamoidectomy. Screws seem darn near impossible to me just based on the peanut size... you could maybe try a threaded k-wire, but those are so fragile at the small sizes?

Have you done a sesamoidectomy yet? Those "little" bones are not that little. I'd try an oRIF w/ screws from the synthes hand modular set. they have 1.3 and 1.5 screws which should be small enough.

 

[NatCh]

Screws seem darn near impossible to me just based on the peanut size... you could maybe try a threaded k-wire, but those are so fragile at the small sizes?

How about using an itty-bitty, teeny-weeny, little external fixator? Ha.

I'd like to watch someone fixate the fragments just to see it done. Those sesamoids can be pretty small, plus there's an awful lot of soft tissue enveloping them. Most often I see transverse fx. lines across sesamoids, so to install a small screw the driver would have to be oriented anterior to posterior...how do you fit it??? Percutaneous???

I wonder if a 1.2mm OSStaple would fit? You'd probably have to remove it later after the fx. heals, but at least it would provide compression.

My daughter just got braces, so in my head I imagined consulting Orthodontics so they can put braces on the sesamoid!

 

[krabmas]

How about using an itty-bitty, teeny-weeny, little external fixator? Ha.

I'd like to watch someone fixate the fragments just to see it done. Those sesamoids can be pretty small, plus there's an awful lot of soft tissue enveloping them. Most often I see transverse fx. lines across sesamoids, so to install a small screw the driver would have to be oriented anterior to posterior...how do you fit it??? Percutaneous???

I wonder if a 1.2mm OSStaple would fit? You'd probably have to remove it later after the fx. heals, but at least it would provide compression.

My daughter just got braces, so in my head I imagined consulting Orthodontics so they can put braces on the sesamoid!

Too funny.

If you make a curved linear incision in the first intermetatarsal space plantarly and lift a full thickness flap of skin over the sesamoids that should give pretty good exposure. The question is how it reattach the FHB if iotragenically ruptured?

 

[PADPM]

In my opinion, this is one of those situations where I believe we may "overthink" things a little bit.

Yes, there are small screw sets that we can borrow from oral surgeons/mandibular screws, that can be used for a sesamoid fracture, but we've got to consider whether the treatment is worse than the condition.

krabmas incision is certainly reasonable, but naturally scar tissue can develop even if the incision is placed in a non weightbearing space. Add fibrous tissue/scar tissue development and you may end up with an entirely new problem!!


Injecting some superglue may be something to explore!

 

[NatCh]

In my opinion, this is one of those situations where I believe we may "overthink" things a little bit.

Yes, there are small screw sets that we can borrow from oral surgeons/mandibular screws, that can be used for a sesamoid fracture, but we've got to consider whether the treatment is worse than the condition.

krabmas incision is certainly reasonable, but naturally scar tissue can develop even if the incision is placed in a non weightbearing space. Add fibrous tissue/scar tissue development and you may end up with an entirely new problem!!


Injecting some superglue may be something to explore!

Interesting idea with the superglue. I've never had the need to do sx. for a sesamoid fx. Conservative care has always worked for me, but I haven't had any elite or pro athletes with this problem. I wonder if injecting some DBM then adding an Exogen would give decent results?

 

[skiz knot]

I wonder if injecting some DBM then adding an Exogen would give decent results?

Is this thread a joke? Superglue? Inject DBM? Bone stimulators?

Think about fracture healing. What is required is blood supply, (relative) apposition of fracture fragments, and at least some form of immobilization. At this point in time I know of no "glue" that will hold fractures together and allow bone to heal. The other two options are adjuncts to treatment which may improve results. On their own, they will not cause a fracture to heal.

 

[NatCh]

Is this thread a joke? Superglue? Inject DBM? Bone stimulators?

Think about fracture healing. What is required is blood supply, (relative) apposition of fracture fragments, and at least some form of immobilization. At this point in time I know of no "glue" that will hold fractures together and allow bone to heal. The other two options are adjuncts to treatment which may improve results. On their own, they will not cause a fracture to heal.

We covered immobilization and blood supply already...further up the thread.

 

[PADPM]

Is this thread a joke? Superglue? Inject DBM? Bone stimulators?

Think about fracture healing. What is required is blood supply, (relative) apposition of fracture fragments, and at least some form of immobilization. At this point in time I know of no "glue" that will hold fractures together and allow bone to heal. The other two options are adjuncts to treatment which may improve results. On their own, they will not cause a fracture to heal.

Yes genius, it was a joke. If you notice, I stated that I thought that people may be "overthinking" things a little. If you read further, I stated that although there are ways to utiilze small fragment sets such as mandibular screws, we don't want the treatment to be worse than the condition.

And after 20+ years of performing surgery on the foot/ankle I don't need you to tell me that "superglue" isn't used on bones. If you can't recognize sarcasm, that's simply your problem, not mine.