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Saturday, June 2, 2018

Sesamoid Fracture Question: Can it Heal Conservatively

Dr. Blake,

First off, thank you so much for providing a forum for people to learn from you and share info about these topics that are difficult to find answers for.  I am a 42-year-old male (6', 175lbs) with a beautiful wife and 6-year-old daughter.  I have been an active, healthy person my whole life and the only health issues I have had have been minor self-inflicted injuries while doing activities that I love.  I am a former baseball jock but my current activities include mountain biking, snowboarding and walking our wonderful mini-poodles with the family.  All of which I do with passion and skill.

In November 2017, I developed what felt like a Charlie Horse in my left foot during the work day which caused me to have a limp that afternoon.  I did have some prior, minor discomfort in the left foot from what I thought was a strain from playing softball.  That night, when I was gingerly hopping up our hardwood, bullnose stairs barefoot, I stubbed my left toe to the point where it brought me to my knees in mid-air.  I knew something was wrong and my foot confirmed it by swelling up like a balloon.  The swelling extended past my ankle.  I implemented R.I.C.E. and canceled all activities for a while.

I will spare you the details of the triple misdiagnosis (first Xray was December 2017) over the next few months but my foot was actually feeling better through Winter 2018.  I went snowboarding several days, biked, walked the dogs a bit, walked to lunch - all very carefully and not through pain as much as discomfort.  After a slow increase in pain, another opinion was had and an X-ray was taken in March 2018.  It turned out "negative" although they put me in a walking boot and recommended an MRI.  The pain (and curiosity) held steady enough to get the MRI in April 2018.

At the MRI follow-up appointment (my first knowledge of the results) I couldn't process the severity as I had no clue the context: a "subacute mildly displaced ununited fracture to the medial sesamoid".  The gap between the broken pieces was .47cm.  Sesamoidectomy was recommended.  After the initial shock and research of sesamoid fractures online for a few days, the daily crying began.  What have I done!!??  The pain has increased greatly since that appointment as I now know exactly what I am up against.  I am now on crutches, working from home, immobilizing and basically going insane trying to figure out what course of action to take.  I am also now well versed in the pros and cons of surgery vs. conservative treatments.

So now that I have that off my chest, my primary question to you is... given the timeline, imagery, and gap between the broken pieces, is there any chance of avoiding surgery?  I have never really given the bone an opportunity to heal over the course of 6 months.  In fact, it felt like it was healing in January and February 2018 yet was already nonunion per the December 2017 Xray.  Is there any hope this can still heal by conservative treatment?  If the answer is yes or maybe, I will surely have follow up questions but for now, I'm looking to know if you have ever seen someone recover conservatively from a gap as big as mine? 

Please see attached images - they are pictures of pictures but if you need higher quality images I can provide them.  The December 2017 Xray is the image with no measurement noted, the .47cm image is the Xray from March 2018 and the April 2018 MRI is the side shot.

This has turned into a nightmare with the indecision aspect of it particularly taxing on my family and me at the moment.  Any feedback you can give is greatly appreciated.  Thank you so much for your time!

Dr. Blake's comment:
     I thank you so very much for giving me the opportunity to way in on this. The gap is very big so the edges will not go back together. When you stubbed your toe, you must have jerked it upward so that the pull of the tendon pulled the pieces apart. I wonder if it was a bipartite sesamoid, to begin with, and injury separated the two pieces. 
     I remember I had a young boy who did this supposedly in basketball, but it turned out to be separated from slamming on the brakes in the head-on collision with a fence. 
     The question really is it okay for you to function, once the inflammation calms down, with this is a non-union status. There is a chance for sure, that once you get this calmed down, if you can get it calmed down, that this will be pain-free. It will take you time, but I would try if it was my toe. 
     One of the key images you sent was the lateral (side view) from the MRI. What is striking, more than the x-rays is the lack of bone response in the sesamoid in two pieces.
This is very unusual that an injured sesamoid shows no sign of bone reaction throughout the sesamoid. Very unusual.  

    So maybe this is not a sesamoid fracture, but a sprain of a bipartite sesamoid. Good chance this could heal, and your body is already used to it in two pieces. Do you have any old x-rays of this foot? 
     In actually even the fibular sesamoid looks beat up and could be part of the problem. 
     The side view also shows the big toe dropped lower on the metatarsal then it should. Do you remember if the toe went up or down, you may have torn a ligament and have some version of turf toe? If you have surgery, it could be just to sew up a ligament. 
     Too many questions from my end to just say go under the knife, although that is my bent in life, and my bias that you have to accept. Has anyone evaluated for a ligament tear? Please mail me a copy of the CD on the MRI so I can review. The address is Dr. Rich Blake, 900 Hyde Street, San Francisco, CA, 94109. There is not a charge for this. The next 2 months do what you can to create the 0-2 pain level with a boot, etc, and ask questions about the possibility of bipartite sesamoid sprain, tendon tear of the hallucis brevis, ligament tear, etc. Someone needs to at least entertain thinking outside the box. I hope this helps some. Rich

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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.