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Saturday, October 14, 2017

Sesamoid Fracture: Email Advice

     Hello, I have been reading through all of your blogs looking for all wisdom you have shared regarding sesamoid fractures

     I am a 53-year-old male in good physical condition(ran 3 times a week prior to the accident and continue to lift though only upper body now). On June 19th of this year, I fractured my right tibial sesamoid when I jumped from a lift at work. The fracture was initially misdiagnosed as a normal bi-partite bone so no conservative treatment was administered. It was very painful and swollen bottom, top and side of the foot.

     On Aug 3 was released from care by the "work care' Dr. and told that the swelling and pain was most likely gout.  On Aug 30 after a very painful flare-up went to urgent care center suspecting gout. Uric acid test, as well as fluids drawn from toe joint, showed no sign of gout.

     Saw a podiatrist on Aug 31 who took another x ray of the foot as well as an x-ray of the left foot for comparison and she confirmed the fracture. Was placed in an air cast rocker boot and told to restrict activities. Had another x-ray on Sept 30 (at the four-week point in boot cast) Podiatrist said she saw little if any healing.   
Dr Blake's comment: During the initial stage, if though gout was misdiagnosed, were you able to get fairly pain free for healing? X-rays are very poor to follow the progress of sesamoid, or any bone, fractures. 

    Started using a bone stimulator (first a borrowed Orthofix for a week, then for the last week I have used an exogen 4000 each day. Had a cat scan on Oct 11 that notes say bone is in the healing stage. Saw my podiatrist on Oct 14. She said upon examining the cat scan the two fragments were healing and would continue to do so but they would not fuse back together but that was fine it shouldn't be a problem. After all, many people naturally have bi-partite sesamoids. 
Dr Blake's comment: We see a ton of sesamoid injuries, most have healed enough that the patients are back to full activity with initially some protection of orthotics, dancer's padding, cluffy wedges, and spica taping. If we forced all of these patients to x-ray, even when clinically they have had a full recovery, the x-rays or CT scan would only show partial healing. It is the internal strength of the healing fracture that matters, and of course, some probably develop a non-painful non-union. This is why I like MRIs to follow sesamoid injuries. MRIs tell the amount of bone healing, and comparisons say 6 months apart, can really give us an idea how the healing is going. I get CT scans when I am worried about avascular necrosis or first metatarsal bone problems. 

    From the countless blogs and articles I have read this doesn't sound like the optimistic report that she is giving me. Can a non-union fractured sesamoid continue to function properly? 
Dr Blake's comment: Very individual. You would assume that the higher level of activity an athlete does, the less chance that would be comfortable. There are too many ifs, ands, and buts in your case. Get an MRI soon, and be ready to get another one 6 months from then to check on healing. The MRI is so sensitive to how sensitive the bone is now by the bone edema noted. Unfortunately sesamoid bones, since weight bearing, can be very sore, even when technically healed, due to nerve hypersensitivity, inflammation in the bone as in presses against the ground or first metatarsal, and from mechanical pulling of the tendons, the bending of the toe, the foot pronation force,etc. They can be so easy to teach, and then some are very challenging. 
     I currently don't have pain in my sesamoid area. I am however still in the walking cast boot. In addition I have a pre-existing bunion on this foot that has never presented any symptoms prior but now seems to become red, swollen and very tender a few times a week. When it does this there is also pain in big toe joint when moved. I am committed to using the bone stimulator for as long as necessary, do contrast baths once a day, ice once or twice daily. I also take calcium, a multi vitamin and vitamin D. I have attached a copy of the CAT scan report. I also have disk with images of all x-rays and the CAT scan in my possession. Any advice is greatly appreciated and much needed.Thank you very much for reading this.
Dr Blake's comment: You have a great attitude since you want to keep that sesamoid. Please get the MRI (do not need contrast dyes), and then send the discs and I will be happy to review. Good luck. Rich The CT Report sent:

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.