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Old 03-04-2012, 01:07 PM   #1
Edwin Detritus
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Sesamoid bipartite or broken?

Hi all,

I’ve been unable to get a proper diagnosis on a sesamoid injury. If you have experience in this area, I’d love to hear from you. My questions are at the end of this post.

The short story:

A year and a half after injuring my right fibular sesamoid, it still gives me a lot of pain. Despite X-rays, MRIs and CTs, I haven’t been able to get a diagnosis on whether it’s naturally bipartite and has a stress fracture (or perhaps is simply bruised), or if the bone was snapped in two pieces and is now a non-union. I’m looking for advice regarding getting a proper diagnosis and treatment.

The long story:

In August 2010 I went on a mountain trail run wearing Vibram Five Fingers. Unexpectedly, I had to make the downhill return trip on the trail as well over broken rock and such. All told it was about 3 hours of hiking over rough terrain. By the end of it I knew I had done damage to my feet. The last portion of the trail was very painful. The next day was even worse. I went to emergency where they did an x-ray and discharged me with “Nil acute, bipartite sesamoid“. Figuring I was just sore from soft tissue trauma, I started icing and staying off my feet as much as possible. A month later I still had a few sharp pains, but I had committed to a running group and so for the next month I ran every day for about 30 minutes wearing runners.

Fast forward another 6 months to April 2011. I relocated for work and wasn’t very active during this period. I started doing some light jogging in runners, then one day pulled out the Vibrams and did a flat trail run. About the same time I started using a standing desk at work. After a few weeks of this I started noticing some bad pains in my right foot. I started rolling a lacrosse ball under my desk, figuring it was just old scar tissue. I started having terrible knee pain to the point my physiotherapist sent me for an MRI on the knee which came back negative. I couldn’t walk down stairs it was so bad. In hindsight it was pretty simple: I had changed my walk dramatically, compensating for several foot injuries received on the original hike, and my hip, knee and ankle were beginning to pay the price. This all became clear when I stood up from sitting one day at the end of June (11 months after the original injury) and it felt like someone drove a nail through my right foot.

I got in to see a respected podiatrist in the San Francisco area, and an MRI of the foot revealed the pain to be a Morton’s Neuroma between the 3rd & 4th metatarsal (with a matched one , less severe, on the left side.) More interesting though was the finding of “bipartite fibular sesamoid at the 1st MTP joint... there is bone edema throughout the proximal and distal fragments”. The podiatrist diagnosed a stress fracture on the sesamoid, put me in a walking boot and had me get a bone stimulator to use every day. For the neuroma he put in a shot of cortisone (the first of two) and put me on some nerve-deadening cream. I wore the boot for a month, then switched to some custom orthotics that protect both the sesamoid and the neuroma. Six months later I went in for another scan of the foot, this time a CT scan (for some reason insurance would cover this, but not a 2nd MRI). Apparently a CT is unable to pick up bone edema, so I wasn’t able to get a true comparison to the earlier MRI. The report stated “The sesamoid appears bipartite” and this little gem: “...the suggestion of a tiny amount of bridging bone between these fragments”.

“Bridging bone”?! From what I understand, a naturally bipartite sesamoid doesn’t suddenly try to sprout a bridge. The podiatrist agreed with this. This means that if what showed up on the scan really is an effort for the two pieces to fuse, then that bone isn’t naturally bipartite - I snapped it in two on the hike and it’s been in two pieces ever since. This would explain both the pain and bone edema.

Apparently sesamoids are reluctant to heal; they get poor blood supply and are continually being stressed by weight bearing. After a year and a half the likelihood of a successful fusion is poor. If it finally fails, the bone must be removed surgically. But this is all based on the assumption it is broken. I’m still not sure of that. The bone shows no signs of necrosis, which it often will do if broken and left non-union this long so I don’t want to have surgery prematurely.

So after all that, here are my questions:

1) Does anyone have experience with sesamoid injuries? How are they best diagnosed? Is there a test (a bone scan perhaps?) that can determine conclusively if the bone is naturally bipartite or whether it’s broken in two?

2) Does anyone have any experience with the rehabilitation of a fractured sesamoid? How long did it take (if at all)? Once the bone healed, what additional therapy was required?

3) Has anyone had surgery to remove the sesamoid (sesamoidectomy)? Are you happy with the decision? Any advice or recommendations you can make?

Thanks so much for your help.
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Old 03-04-2012, 04:20 PM   #2
Sean Rockett
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Re: Sesamoid bipartite or broken?

Quote:
Originally Posted by Edwin Detritus View Post
Hi all,

I’ve been unable to get a proper diagnosis on a sesamoid injury. If you have experience in this area, I’d love to hear from you. My questions are at the end of this post.

The short story:

A year and a half after injuring my right fibular sesamoid, it still gives me a lot of pain. Despite X-rays, MRIs and CTs, I haven’t been able to get a diagnosis on whether it’s naturally bipartite and has a stress fracture (or perhaps is simply bruised), or if the bone was snapped in two pieces and is now a non-union. I’m looking for advice regarding getting a proper diagnosis and treatment.

The long story:

In August 2010 I went on a mountain trail run wearing Vibram Five Fingers. Unexpectedly, I had to make the downhill return trip on the trail as well over broken rock and such. All told it was about 3 hours of hiking over rough terrain. By the end of it I knew I had done damage to my feet. The last portion of the trail was very painful. The next day was even worse. I went to emergency where they did an x-ray and discharged me with “Nil acute, bipartite sesamoid“. Figuring I was just sore from soft tissue trauma, I started icing and staying off my feet as much as possible. A month later I still had a few sharp pains, but I had committed to a running group and so for the next month I ran every day for about 30 minutes wearing runners.

Fast forward another 6 months to April 2011. I relocated for work and wasn’t very active during this period. I started doing some light jogging in runners, then one day pulled out the Vibrams and did a flat trail run. About the same time I started using a standing desk at work. After a few weeks of this I started noticing some bad pains in my right foot. I started rolling a lacrosse ball under my desk, figuring it was just old scar tissue. I started having terrible knee pain to the point my physiotherapist sent me for an MRI on the knee which came back negative. I couldn’t walk down stairs it was so bad. In hindsight it was pretty simple: I had changed my walk dramatically, compensating for several foot injuries received on the original hike, and my hip, knee and ankle were beginning to pay the price. This all became clear when I stood up from sitting one day at the end of June (11 months after the original injury) and it felt like someone drove a nail through my right foot.

I got in to see a respected podiatrist in the San Francisco area, and an MRI of the foot revealed the pain to be a Morton’s Neuroma between the 3rd & 4th metatarsal (with a matched one , less severe, on the left side.) More interesting though was the finding of “bipartite fibular sesamoid at the 1st MTP joint... there is bone edema throughout the proximal and distal fragments”. The podiatrist diagnosed a stress fracture on the sesamoid, put me in a walking boot and had me get a bone stimulator to use every day. For the neuroma he put in a shot of cortisone (the first of two) and put me on some nerve-deadening cream. I wore the boot for a month, then switched to some custom orthotics that protect both the sesamoid and the neuroma. Six months later I went in for another scan of the foot, this time a CT scan (for some reason insurance would cover this, but not a 2nd MRI). Apparently a CT is unable to pick up bone edema, so I wasn’t able to get a true comparison to the earlier MRI. The report stated “The sesamoid appears bipartite” and this little gem: “...the suggestion of a tiny amount of bridging bone between these fragments”.

“Bridging bone”?! From what I understand, a naturally bipartite sesamoid doesn’t suddenly try to sprout a bridge. The podiatrist agreed with this. This means that if what showed up on the scan really is an effort for the two pieces to fuse, then that bone isn’t naturally bipartite - I snapped it in two on the hike and it’s been in two pieces ever since. This would explain both the pain and bone edema.

Apparently sesamoids are reluctant to heal; they get poor blood supply and are continually being stressed by weight bearing. After a year and a half the likelihood of a successful fusion is poor. If it finally fails, the bone must be removed surgically. But this is all based on the assumption it is broken. I’m still not sure of that. The bone shows no signs of necrosis, which it often will do if broken and left non-union this long so I don’t want to have surgery prematurely.

So after all that, here are my questions:

1) Does anyone have experience with sesamoid injuries? How are they best diagnosed? Is there a test (a bone scan perhaps?) that can determine conclusively if the bone is naturally bipartite or whether it’s broken in two?

2) Does anyone have any experience with the rehabilitation of a fractured sesamoid? How long did it take (if at all)? Once the bone healed, what additional therapy was required?

3) Has anyone had surgery to remove the sesamoid (sesamoidectomy)? Are you happy with the decision? Any advice or recommendations you can make?

Thanks so much for your help.
Bone scan would be helpful to show stress fracture (it will light up) vs. bipartite patella ( it will not light up). Typically acute fracture of sesamoid can take 3 months to get better with modification and not stressing it. Most of the are bipartites with stress at the junction or synchondrosis. Would strat with boes scan or re-examination
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Old 03-04-2012, 06:12 PM   #3
Edwin Detritus
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Re: Sesamoid bipartite or broken?

Thanks Sean,

The sesamoid "lights up" on an MRI due to the edema. The podiatrist's initial diagnosis was a stress fracture because of this. If this same edema will cause the same on a bone scan, can it still differentiate between a stress fracture and a complete break in two? My goal is to determine if the bone is naturally bipartite and has a stress fracture, or if it is broken in two pieces.
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Old 03-04-2012, 07:47 PM   #4
Sean Rockett
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Re: Sesamoid bipartite or broken?

Quote:
Originally Posted by Edwin Detritus View Post
Thanks Sean,

The sesamoid "lights up" on an MRI due to the edema. The podiatrist's initial diagnosis was a stress fracture because of this. If this same edema will cause the same on a bone scan, can it still differentiate between a stress fracture and a complete break in two? My goal is to determine if the bone is naturally bipartite and has a stress fracture, or if it is broken in two pieces.
Typically one can see the contour on a CT scan to see if there are jagged edges like a fresh break or smooth edges like a bipartite.
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Old 03-05-2012, 12:32 AM   #5
Edwin Detritus
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Re: Sesamoid bipartite or broken?

Are they jagged only while the break is fresh? I've been walking on it for 19 months now, and I imagine I'm grinding those ends against each other with every step.
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Old 03-05-2012, 09:34 AM   #6
Sean Rockett
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Re: Sesamoid bipartite or broken?

Quote:
Originally Posted by Edwin Detritus View Post
Are they jagged only while the break is fresh? I've been walking on it for 19 months now, and I imagine I'm grinding those ends against each other with every step.
if it has been 19 months it will not be jagged so you are left with either a painful bipartite or a nonunion of an old fracture.
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Old 03-05-2012, 10:19 AM   #7
Edwin Detritus
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Re: Sesamoid bipartite or broken?

Yes. That's exactly what I'm trying to determine.
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Old 03-05-2012, 08:19 PM   #8
Sean Rockett
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Re: Sesamoid bipartite or broken?

Quote:
Originally Posted by Edwin Detritus View Post
Yes. That's exactly what I'm trying to determine.
go to this link:
http://www.wheelessonline.com/ortho/sesamoid_fractures
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Old 03-05-2012, 10:14 PM   #9
Edwin Detritus
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Re: Sesamoid bipartite or broken?

Sean, thanks for your help but I think we've got crossed wires on what I'm trying to learn here.

Anyone have experience with this kind of injury? Specifically, I'm looking for definitive diagnosis on whether the sesamoid is bruised but naturally bipartite, or snapped in two. Your personal experience with diagnosis, rehab, surgery, etc, is all welcome.
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Old 03-06-2012, 01:41 PM   #10
Sean Rockett
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Re: Sesamoid bipartite or broken?

Quote:
Originally Posted by Edwin Detritus View Post
Sean, thanks for your help but I think we've got crossed wires on what I'm trying to learn here.

Anyone have experience with this kind of injury? Specifically, I'm looking for definitive diagnosis on whether the sesamoid is bruised but naturally bipartite, or snapped in two. Your personal experience with diagnosis, rehab, surgery, etc, is all welcome.
What you are trying to learn is difficult over the internet, because a physical exam is part of the definitive diagnosis. I would recommend you see a foot ankle orthopedist if you want a definitive diagnosis.
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