sesmoid/ turf toe/hallux varus Flashcards by Sally-Anne Phillips

What are the two sesmoids called?

Medial- tibial
- larger, greater weight bearing status, more commonly injured
Lateral - fibular
Bipartite sesmoids present in 10-25%
- 97% tibial sesmoid
- 25% bilateral

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What are they envelopes between?

Flexor hallicis brevis

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What are they separated by?

A Crista- inter sesmoid ridge

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How are they attached to the proximal phalanx?

By the plantar plate

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What are they suspended by ?

Collateral lig of mtp joint,
metatarasesmoid junction
intersesmoid lig,
adductor hallicis longus ,
adductor hallicis tendon

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What are their functions?

Absorb weight bearing pressure
Reduce Friction at MT head
Protect FHL tendon
- glides between sesmoids
Provides Fulcrum for flexor hallucis brevis that increases MTP Flexion power
To increase mechanical advantage of pulley function of intrinsics - fhb

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Which sesmoid fractures?

The tibial- also greater chance of bipartitite

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What is the mechanism of sesmoid fracture?

Forced dorsiflexion of first MTP
- most common
- potential avulsion of plantar plate off base of phalanx
- proximal migration of sesmoids

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What are the signs & symptoms of a pt with sesmoid injury?

Symptoms

Generalized big toe pain
- worse in terminal part of stance phase

Sign

Possible plantar-flexed MTP with cavus foot

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Name associated conditions of sesmoid injury?

Bilateral sesmoiditis shoud raise concerns for
Reiter’s disease
- urethritis, conjuctivitis, iritis, inflammatory bowel disease
Psoriatic disease
Seronegative RA

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What investigations are helpful for dx semsoid injury?

Xrays

AP and lateral foot standing
medial oblique (sesmoid view)
Axial sesmoid view
- proximal migration of sesmoids- suspicious of inrinsic minus hallux

Bone scan

Helps distinguish bipartite sesmoid from a fracture
increase uptake cf contralateral side helps dx

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What is the mx of sesmoid fractures?

Non operative

NSAIDs, Reduced WEightbearing,Activity modification, orthoses
BK leg cast with toe extension
- Fracture boot- limit stress across sesmoid Transition to sesmoid pad with gradual return to activity

Surgery

Partial or complete sesmoidectomy
- symptomatic post 3-12 months
Autologous Bone graft
- Non union/fracture
Dorsiflexion Osteotomy
- Plantar-flexed 1st ray with sesmoid injury

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What portion of the sesmoid is ok to remove ?

Distal or proximal pole - best results

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Decribe the approach for excision of tibial sessmoid?

Medial -plantar approach
HIgh risk of injury to Proper branch if medial plantar nerve

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Describe the approach for excision of fibular sesmoid

Plantar approach
Beware if proper branch to lateral side of hallux
first branch to first web space

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What are he complications of seamoidectomy?

Cock up deformity
- - with removal of both sesmoids!!
- weakness of Flexor hallucis brevis- should be repaired post excision
Hallux valgus
- _tibial s_esmoid excision
Hallux varus
- _fibular s_esmoid excision

Wjat is the mechanism for a turf toe?

Forced dorsiflexion of 1st mtpj- avulsion of plantar plate - with proximal migration of sesmoids

What is Turf toe?

Hyperextension injury to plantar plate and sesmoid complex of hallux metatarsophalangeal joint MTPJ

What is the epidemiology of turf toe?

More prevalent in contact atheletes sports on rigid sufaces

What is the pathoanatomy of Turf toe?

Forefoot is fixed to ground
Hallux MTPJ positioned in hyper-extension
Axial load is applied ot heel
combination of force and joint positoning causes attenuation or tearing of plantar capsular ligamentous complex
tear occurs off proximal phalanx not metatarsal

Name associated injuries of turf toe?

Varus, valgus injuries of hallux MTPJ
Sesmoid fracture
proximal migration of ssesmoid
cartilaginous injury/ loose body in hallux MTPJ
Stress fracture of proximal phalanx
Hallux rigiditus

What structure stabilise the MTPJ of hallux?

Osseous structures
- articulation between MT /proximal phalanx
Tendons
- Flexor hallucis brevis
  - contains tibial/fibular sesmoids
  - medially abductor hallucis
  - laterally adductir hallucis
Ligaments
- Medial and lateral collateral ligaments
- intermetatarsal ligaments
PLantar plate
- Composed of joint capsule
- attaches to transverse head of ABDUCTOR hallucis, felxor tendon sheath adn deep transverse intermetatarsal ligament

What are the signs and symptoms of turf toe?

Symptoms

acute pain
stiffness
swelling
inability to push off
reduced agility

Signs

Plantar swelling
Ecchymosis
Alignment of hallux MTPJ
Inabliity to extend
Vertical Lachman test- Greater laxity cf opposite side

What investigations are helpful lin Dx of turf toe?

Xray

WB AP, lateral, oblique foot
sesmoid axial view
- medial sesmoid may be displaced proximally
- may show sesmoid fracture

Bone scan

Negative radiograph with persistent pain, swelling, weak toe push off
stress fracture of proximal phalanx

MRI

Positive bone scan
Persistent pain and swelling
- disruption of plantar plate seen

Describes the grades and tx options?

* **Grade 1** * _ strain_ of _plantar plate_ * normal rom/ X-rays-stiff insole , taping, immediate return to play * **Grade 2** * _Partial tear of plantar plate_ * Painful rom, limited wb * normal xrays * _stiff sole shoe/rocker bottom to limit motion, no play 2 weeks_ * **Grade 3** * _complete capsular tear of plantar plate_ * severe pain on wb/ rom * **surgical repair of plate** has better outcome cf consx * medial plantar incision * repair of excision of sesmoid depends on fragmentation * headless screw/ suture repair * immediate post op non wb * return to sport 3-4 months

Decribe the complications of turf toe?

* **Hallux rigiditus** * late sequela * tx with cheilectomy versus arthrodesis, depending on severity * **Proximal phalanx stres fracture** * may be overlooked

Define hallux varus?

* Medial deviation of great toe relative to 1st Metatarsal

What is the aetiology of Hallux varus?

* **Overcorrection during hallux varus surgery**- most common * Over release of lateral capsular structures * Overplication of medial capsule * excessive resection of medial eminence * overcorrection of IMA * Excision of fibular (lateral )sesamoid

What are the signs and symptoms of hallux varus?

Symptoms * Often asymptomatic * **diffculty with shoe wear** is most common * pain , decreased rom, instability, weakness with push off Sign * **Varus positioning of great toe** * ER/Supination of foot, walking on lateral border of foot to avoid toe off * often have IPJ felxion and MTPJ extension * EHL maybe medially displaced-? bowstring dynamic deformity * tibial (_medial ) sesamoid my be medially_ displaced

What investigations are helpful in ddx of hallux varus?

Xrays * WB AP, lateral, sesamoid axial views * **Hallux valgus angle less than or = 0^o**

What is the tx of hallux varus?

Non operative * **Shoe modification to accomodate the deformity** * extra depth adn wider more flexible toe box * placing pads over prominent toes Operative * **Abductor hallucis release & transfer of EHL or EHB to proximal phalanx** * For flexible deformities * transfer portion of EHL/EHB under transverse intermetatarsal ligament to distal metatarsal neck ( from lateral to medial) * Distal portion of tendon left intact, creating static stabiliser * **1st MTP Arthrodesis** * fixed deformity * significant arthrosis