Site Search:

Question for Physiotherapists

QUESTION | What is the best management for a patient with fractures of both the radial and ulnar sesamoids of the thumb due to a fall?


ANSWER |  Sesamoids are bones which are encased within a tendon. The patella is the largest sesamoid bone in the body, within the quadriceps tendon. In the hand and wrist, the pisiform bone is the largest named sesamoid, within the flexor carpi ulnaris (FCU) tendon. Other relatively consistent sesamoids are found at the thumb at the level of the head of the metacarpal within the flexor pollicis brevis (FPB) and adductor pollicis brevis (APB) tendons. They are also sometimes found in the flexor tendons at the level of the metacarpal heads of the little and index finger, or at the head of the proximal phalanx of the thumb. Although these are usually rounded discrete bones, sometimes they are bipartite – that is, formed in two pieces, both of which remain visible on x-ray – and this appearance can be mistaken for a fracture, especially if there has been some kind of trauma.

Pain from the hand and wrist sesamoid bones are uncommon.

   
 

Sesamoid bones of the thumb indicated by arrows

The most common problem would probably be a fracture of the pisiform from a fall onto an outstretched hand or a direct blow. These are treated symptomatically with oral analgesia, splint, rest and gradual reintroduction of activities. In cases of displaced fractures, or undisplaced fractures that continue to cause significant pain beyond about 6 weeks, pisiform excision and repair of the overlying FCU tendon gives good pain relief without any functional impairment.  

Degenerative osteoarthritis can also affect the sesamoid bones, such as between the pisiform and the triquetrum. Degenerative arthritis around the sesamoid bones of the flexor tendons of the digits can also occur. In these scenarios, the grinding and clicking from the movement of the sesamoid bone can mimic a trigger digit. Non-operative treatment is in line with that of most other arthritic joints – that is, temporary immobilisation in a splint, oral analgesia, injections of local anaesthetic and steroid, and functional rehabilitation. In cases of unremitting pain, the sesamoid bones can be excised without functional loss. If there is any doubt as to whether or not there is a concomitant  trigger digit, a trigger release can be done simultaneously.  

So, to the original question about a patient with fractures of the ulnar and radial sesamoids of the thumb due to a fall, one must wonder whether in fact these were bipartite sesamoid bones and warn the patient that the radiological appearance of being fractured may not change with time. Regardless, the treatment for pain would be temporary immobilisation and analgesia, regardless of whether these are true fractures or not. A hand based thermoplastic splint that immobilises the CMC and MCP joints of the thumb should be sufficient, although it may sometimes be necessary to immobilise the IP joint as well. After about 4 weeks of splinting, if the pain is not subsiding, then I would consider an injection of local anaesthetic and steroid under ultrasound guidance. If the pain still remains, an excision of the sesamoids along with a release of the flexor tendon pulley can be performed.

    Dr Kwan Yeoh

    If you are a physiotherapist and wish to be sent the Question for Physiotherapists or you would like to submit a Question please email question@orthosports.com.au including your name and practice. 


    Previous Question for Physiotherapists:

    Feb-2017  Plantar Fasciitis
    Dr Todd Gothelf
    Nov-2016  Sternoclavicular Joint Dr Doron Sher 
    Oct-2016  Proximal Humerus Fractures Dr David Lieu 
    Sep-2016 Wrist Fractures  Dr Kwan Yeoh 
    Aug-2016  Patella Instability Dr Doron Sher 
    Jul-2016 Snowboarders ankle
    Dr Todd Gothelf
    May-2016  Cortisone Injections Dr Paul Annett 
    Apr-2016 Shoulder Instability_1  Dr Ivan Popoff 
    Mar-2016 Exercise after TKR  Dr Doron Sher 
    Dec-2015 Scaphoid OA Dr Kwan Yeoh 
    Nov-2015  Greater Tuberosity Fractures Dr Doron Sher
    Oct-2015 Stress Fractures  Dr Paul Annett
    Sep-2015
    Boxers Fractures
    Dr Kwan Yeoh
    Aug 2015
    Resistance Training  Dr John Best
    July 2015 LARS Ligament
    Dr Ivan Popoff
    Jun-2015
    Distal Biceps  Dr Doron Sher
    May-2015 Latarjet procedure
    Dr Jerome Goldberg
    Apr-2015 TFCC Questions  Dr Kwan Yeoh 
    Mar-2015  Acute Ankle Sprains
    Dr Todd Gothelf
    Dec-2014  Thoracic spine and ribs Dr Mel Cusi
    Nov-2014  PRPP Dr Paul Annett
    Oct-2014 Driving After Surgery
    Dr Doron Sher
    Sep-2014  Distal Biceps Rupture Dr Doron Sher
    Aug-2014 Ankle Sprain
    Dr Todd Gothelf
    Jun-2014  Patella Dislocation Dr Doron Sher
    May-2014  Shoulder Instability Dr Todd Gothelf
    Apr-2014  De Quervains Dr Kwan Yeoh
    Mar-2014
    Acromio-clavicular joint injuries
    Dr Todd Gothelf
    Feb-2014 Chronic Knee Pain
    Dr Paul Annett
    Dec-2013 Foot and Ankle Questions  Dr John Negrine
    Nov-2013
    SIJ Questions  Dr Mel Cusi
    Oct-2013 Rotator Cuff Repair  Dr Todd Gothelf
    Sep-2013  ACL Reconstruction
    Dr Doron Sher
    Jul-2013 Slipped Upper femoral epiphysis  Dr Rod Pattinson
    May-2013 Skiers thumb Dr Kwan Yeoh
    Apr-2013  Bakers_Cyst
    Dr Ivan Popoff

    Mar-2013

     Tibial Osteotomy vs UKR

    Dr Doron Sher 
    Feb-2013

     ALIF success rate

    Dr Andreas Loefler

    Jan-2013

     Lisfranc Injuries

    Dr Todd Gothelf 
    Nov-2012

     Anterior Spinal Fusions

    Dr Andreas Loefler 
    Oct-2012 

     MCL Injuries

    Dr Doron Sher 
    Sept-2012

    Compartment Syndrome

    Dr Paul Annett 
    Aug-2012   

     Carpal tunnel

    Dr Kwan Yeoh 
    July-2012

     Anterior Process Calcaneus Fx

    Dr Todd Gothelf 
    Jun-2012

     Tenodesis vs Tenotomy

    Dr Jerome Goldberg 

    May-2012

     Osteoarthritis in the young active patient Dr Doron Sher 
    April-2012

     Syndesmosis Sprain

    Dr Todd Gothelf 

    Mar-2012

     Triangular Fibrocartilage Injuries

    Dr Kwan Yeoh 
    Feb-2012

     Acute Low Back Pain

    Dr Mel Cusi 
    Jan-2012

     Shoulder Replacement Older Population

    Dr Jerome Goldberg

    Dec-2011

     

     Wrist Fracture

    Dr Kwan Yeoh 

    Nov-2011

     

     Adductor Tendon Tear

    Dr Paul Annett 
    Oct-2011

     Navicular Pain 

    Dr Todd Gothelf 
    Sept-2011

     OCD Lesion

    Dr Doron Sher 
    Aug-2011

     Metal on Metal Hip Replacements

    Dr Andreas Leofler 
    July-2011

     Femoral Neck Stress Fract (Pt 2)

    Dr John Best 

    Jun-2011

     Femoral Neck Stress Fractures

    Dr John Best 
    May-2011

     PCL Injury Part 2

    Dr Doron Sher 
    April-2011

     PCL Injury Part 1

    Dr Doron Sher 
    Mar-2011

     Prolotherapy Autologous Blood Injections

    Dr Paul Annett 
    Feb-2011

     Shoulder Impingement

    Dr Todd Gothelf 
    Dec-2010

     Does Chondral Grafting Work

    Dr Doron Sher 
    Nov-2010

     Shoulder Immobilisation-Dislocation

    Dr Jerome Goldberg
    Sept-2010

    SLAP Lesions Stable Shoulder

    Dr Todd Gothelf 
    Aug-2010

     Patellofemoral Crepitus

    Dr Mel Cusi 
    Jul-2010

     Ankle Sprains

     Dr Todd Gothelf

    Jun-2010

     Dislocation After THR

     Dr Peter Walker

    May-2010

     Acupuncture Muscle Strength Programmes

     Dr Paul Annett

    April-2010

     Full Thickness Rotator Cuff Tears

    Dr Jerome Goldberg

    Mar-2010

     Skiing after TKR

     Prof Warwick Bruce

    Feb-2010

     Fractures of the Clavicle

     Dr John Trantalis

    Jan-2010

     Osteoarthritis of the Knee

     Dr Doron Sher

    Dec-2009

     Fifrth Metatarsal Fractures

     Dr Todd Gothelf

    Nov-2009

    Partial Rotator Cuff Tears

    Dr Todd Gothelf

    Copyright © 2009 Orthosports
    Heel Pain - Colles Fracture - Shoulder Rehabilitation

    Orthopaedic Surgeon - Knee Reconstruction - ACL tear - Osteotomy
    Orthopaedic Surgeon

    name:
    Enter your email address:
    CONCORD 02 9744 2666 | HURSTVILLE 02 9580 6066 | PENRITH 02 4721 7799 | RANDWICK 02 9399 5333 | BELLA VISTA 02 9744 2666
    Copyright © 2009 Orthosports