sesmoid/ turf toe/hallux varus Flashcards
1
Q
What are the two sesmoids called?
A
- Medial- tibial
- larger, greater weight bearing status, more commonly injured
- Lateral - fibular
- Bipartite sesmoids present in 10-25%
- 97% tibial sesmoid
- 25% bilateral
2
Q
What are they envelopes between?
A
- Flexor hallicis brevis
3
Q
What are they separated by?
A
- A Crista- inter sesmoid ridge
4
Q
How are they attached to the proximal phalanx?
A
- By the plantar plate
5
Q
What are they suspended by ?
A
- Collateral lig of mtp joint,
- metatarasesmoid junction
- intersesmoid lig,
- adductor hallicis longus ,
- adductor hallicis tendon
6
Q
What are their functions?
A
- 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
7
Q
Which sesmoid fractures?
A
- The tibial- also greater chance of bipartitite
8
Q
What is the mechanism of sesmoid fracture?
A
- Forced dorsiflexion of first MTP
- most common
- potential avulsion of plantar plate off base of phalanx
- proximal migration of sesmoids
9
Q
What are the signs & symptoms of a pt with sesmoid injury?
A
Symptoms
- Generalized big toe pain
- worse in terminal part of stance phase
Sign
- Possible plantar-flexed MTP with cavus foot
10
Q
Name associated conditions of sesmoid injury?
A
- Bilateral sesmoiditis shoud raise concerns for
-
Reiter’s disease
- urethritis, conjuctivitis, iritis, inflammatory bowel disease
- Psoriatic disease
- Seronegative RA
11
Q
What investigations are helpful for dx semsoid injury?
A
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
12
Q
What is the mx of sesmoid fractures?
A
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
13
Q
What portion of the sesmoid is ok to remove ?
A
- Distal or proximal pole - best results
14
Q
Decribe the approach for excision of tibial sessmoid?
A
- Medial -plantar approach
- HIgh risk of injury to Proper branch if medial plantar nerve
15
Q
Describe the approach for excision of fibular sesmoid
A
- Plantar approach
- Beware if proper branch to lateral side of hallux
- first branch to first web space
16
Q
What are he complications of seamoidectomy?
A
-
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
17
Q
Wjat is the mechanism for a turf toe?
A
Forced dorsiflexion of 1st mtpj- avulsion of plantar plate - with proximal migration of sesmoids
18
Q
What is Turf toe?
A
- Hyperextension injury to plantar plate and sesmoid complex of hallux metatarsophalangeal joint MTPJ
19
Q
What is the epidemiology of turf toe?
A
- More prevalent in contact atheletes sports on rigid sufaces
20
Q
What is the pathoanatomy of Turf toe?
A
- 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
21
Q
Name associated injuries of turf toe?
A
- 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
22
Q
What structure stabilise the MTPJ of hallux?
A
-
Osseous structures
- articulation between MT /proximal phalanx
-
Tendons
- Flexor hallucis brevis
- contains tibial/fibular sesmoids
- medially abductor hallucis
- laterally adductir hallucis
- Flexor hallucis brevis
-
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
23
Q
What are the signs and symptoms of turf toe?
A
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
24
Q
What investigations are helpful lin Dx of turf toe?
A
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
25
Q
Describes the grades and tx options?
A
-
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
26
Q
Decribe the complications of turf toe?
A
-
Hallux rigiditus
- late sequela
- tx with cheilectomy versus arthrodesis, depending on severity
-
Proximal phalanx stres fracture
- may be overlooked
27
Q
Define hallux varus?
A
- Medial deviation of great toe relative to 1st Metatarsal
28
Q
What is the aetiology of Hallux varus?
A
- 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
29
Q
What are the signs and symptoms of hallux varus?
A
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
30
Q
What investigations are helpful in ddx of hallux varus?
A
Xrays
- WB AP, lateral, sesamoid axial views
- Hallux valgus angle less than or = 0o
31
Q
What is the tx of hallux varus?
A
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
