Sesamoid Fracture Email Advice

Dr. Blake, I am so happy to discover your blog!

     My daughter is 14-years-old, and being recruited for a college athletic scholarship. Comparing x-rays, MRI, and CT scan, the orthopedic has diagnosed a non-union medial sesamoid fracture. The break is horizontally across the middle, so the appearance is similar to a bipartite sesamoid. This was an acute injury, which occurred 11 months ago. Initially, she wore an orthotic shoe for 3 weeks, started to feel better, and was cleared to return to strenuous activity after 3 weeks. Well, here we are 10 months later and she plays in constant pain. Orthotics and taping have not worked at all. The doctor now suggests a non-weight bearing plaster cast for 6 weeks. I am happy to try any non-surgical option!   I have several questions for you. 

#1 Is there a chance cast will work to heal a non-union fracture. 
Dr Blake's comment: Totally, she should be in the Immobilization Phase of Rehabilitation for a 3 month period with a Exogen bone stimulator to use daily. During that time, you want to do contrast bathing once daily, and icing twice per day. She needs to substitute biking and swimming, with strengthening and flexibility workouts, for her main sport. The next 3 months are even harder, as you wean out of the cast, continue anti-inflammatory, keep the pain level 0-2, gradually increase the activities, continue cross training, and feeling loss a lot of the time (important to have a great PT or sports doc to help her through this time). Need to have a good protected weight bearing orthotic at that time. 

#2 If the cast does not work what is her best option to heal this trying to screw the bone or remove it? 
Dr Blake's comment: Most remove all, some partial. When removed, you have to wear protected orthotics forever for sports, and toe separators between the first and second toes in all enclosed shoes to help slow bunion development. 

#3 Are we risking all her years of hard work to get to this point athletically being ruined? 
Dr Blake's comment: If you go conservative, you have to be committed to 6 months of keeping that pain level between 0-2, and another 6 months to have surgery and healing, if the conservative treatment does not work. If you have surgery tomorrow, you will have to give 6 months to healing before she is back to her pre-surgical level of activity. As a physician, if I feel that there is a reasonable chance to heal conservatively, I will always recommend the conservative route, even in the face of loss of college scholarships, etc, because surgical complications can occur. Part is your comfort level with the potential surgeon. This does not mean we do not do surgery in the situation your daughter finds herself in, but at her age, much more caution and opinions are used. 

#4 Should she just play through the pain? 
Dr Blake's comment: No!! Playing through pain does so much damage to the joint potentially, and the rest of the body due to compensations. You also are risking nerve hypersensitivity which can disappear slowly even with surgery.