Sesamoid Fracture: Email Advice

Hi Dr. Blake, 

My 18 year old daughter suffered an injury mid February while dancing.  For five weeks, it went misdiagnosed so nothing was done except to stop dancing.  At five weeks of no improvement, it was diagnosed as a medial sesamoid bone fracture and she started using a walking boot with crutches non weight bearing for three weeks followed by three weeks of walking in a stiff soled padded shoe to take weight off the sesamoid bone.  She also started vitamin D and calcium supplements.  

An x-ray taken at the end of the six weeks showed bone resorption and widening of the fracture. (The fracture is 3/4 of the way through the bone from the bottom).  She was placed back in the boot for four weeks weight bearing (no crutches) and started on an Exogen bone stimulator 20 minutes daily.  This week, an X-ray was taken and the fracture has not improved and may even be worse.  Her doctor advised us to continue with the walking boot for another three weeks, continue bone stimulation then progress to a supportive shoe with padding to offload the sesamoid bone.  He will see us again at the end of six weeks.  I should mention that in the walking boot and padded stiff soled shoe, she is able to achieve pain free walking and she has very little swelling.  The rest of the bone on X-ray appears to be of normal density. For the past three weeks she has also been riding the exercise bike daily.

Dr Blake's comment: You and the doc has done well to achieve a pain free environment to maximize the chance for healing. The xrays are so bad at following these injuries, since the healing process brings increased fluid into the fracture area making it appear worse (less white) when most of the time it is healing just fine. 

All along, our doctor has been rather encouraging, but this appointment he was not and even consulted with a surgeon who said to continue what we were doing as surgery, which is the last option, may decrease function and she would not be able to dance again after.

Dr Blake's comment: I do not agree with this. You lose some flexion function, but you can work on recruiting the tissue not involved to help. I do not think if she had surgery it would end her career. Of course, the younger the patient is the less anyone wants to have a complication which could result in a career ending surgery. But, that is not the expected. 

My question for you is, is there still hope that this bone can heal, especially if the space has widened? Is there anything else, we should be doing to help her heal? Do you recommend that she use the walking boot longer than advised? Do you think that she will ever be able to dance again?

Dr Blake's comment: She has a great chance it will heal, and we do not know if the gap truly is wider. Sounds like you are dealing with nutrition, bone stimulation, off weight bearing, gradually return to activity. Remember, as long as you stay in the 0-2 pain range, you are giving it a chance to heal, but you now need to add more weight, more stress, slowly and carefully, but consistently over the next few months. Have you mastered dancer's pads, and spica taping? You can find these all over my blog. I want a picture of her dancing full out some day. Thanks. Please keep me in the loop. 

Any advice that you give us would be very much appreciated.