sesmoid/ turf toe/hallux varus Flashcards Preview

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Flashcards in sesmoid/ turf toe/hallux varus Deck (31):

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


What are they envelopes between?

  • Flexor hallicis brevis


What are they separated by?

  • A Crista- inter sesmoid ridge


How are they attached to the proximal phalanx?

  • By the plantar plate


What are they suspended by ?

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


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 


Which sesmoid fractures?

  • The tibial- also greater chance of bipartitite


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


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


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


  • Possible plantar-flexed MTP with cavus foot


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


What investigations are helpful for dx semsoid injury?


  • 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


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


  • Partial or complete sesmoidectomy

    • symptomatic post 3-12 months

  • ​Autologous Bone graft

    • ​Non union/fracture

  • Dorsiflexion Osteotomy

    • ​Plantar-flexed 1st ray with sesmoid injury


What portion of the sesmoid is ok to remove ?

  • Distal or proximal pole - best results


Decribe the approach for excision of tibial sessmoid?

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


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


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 sesmoid excision
  • Hallux varus
    • fibular sesmoid 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?


  • acute pain
  • stiffness
  • swelling
  • inability to push off
  • reduced agility


  • 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?


  • 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


  • 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?


  • Often asymptomatic
  • diffculty with shoe wear is most common 
  • pain , decreased rom, instability, weakness with push off


  • 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?


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


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


  • 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