Hallux Sesamoid Fracture

Aka: Hallux Sesamoid Fracture, Sesamoid Fracture

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II. Physiology

  1. Hallux Sesamoids
    1. Two flat bones at plantar first MTP base of great toe
    2. Thumb also has two similar sesamoid bones at the base of the first MCP
  2. Function
    1. Sesamoids are embedded within tendons at high stress joint surfaces of hand and foot
    2. Sesamoids prevent direct tendon stress during weight bearing
  3. Injury
    1. Medial sesamoid (larger) is more commonly injured than lateral

III. Risk Factors

  1. Obesity
  2. Increased weight bearing
  3. Athletes with increased intensity and duration of activity

IV. Mechanism

  1. Trauma due to falls
  2. Great toe hyperextension
  3. Metatarsophalangeal joint (MTP) dislocation
  4. High stress activity at MTP joint in athletes
    1. Sudden twisting or forceful foot/ankle dorsiflexion
  5. Stress Fracture of sesamoid (most common)
    1. Associated with weak tendon strength, inadequate for structural support

V. Symptoms

  1. Medial plantar Foot Pain
  2. Pain on weight bearing and great toe extension

VI. Signs

  1. Pain on palpation of plantar first Metatarsal head
  2. Reduced and painful great toe range of motion
    1. First toe extension refers pain to plantar 1st MTP
  3. Passive axial compression test
    1. Palpate sesamoid bones in neutral toe position
    2. Apply firm pressure immediately proximal to sesamoids throughout testing
      1. First passively dorsiflex the great toe (sesamoids will migrate distally)
      2. Next passively plantar flex the great toe (sesamoids will migrate proximally)
    3. Expect plantar flexion to impede proximal sesamoid migration and result in pain
      1. Pain suggests sesamoid bone related pain (e.g. Fracture, sesamoiditis)

VII. Imaging

  1. Foot XRAY AP and lateral
    1. Fracture usually found on xray
      1. Sharp Fracture line separates uneven sesamoid fragments
    2. Sesamoid partition is a common normal anatomic variant (bipartite hallux sesamoids)
      1. Normal variant of incomplete sesamoid fusion found in 6-14% of overall population
      2. May be difficult to distinguish from Fracture
      3. Bipartite hallux sesamoids have smooth, well-corticated edges
  2. Advanced Imaging
    1. CT or MRI may be considered when XRay is repeatedly non-diagnostic

VIII. Differential Diagnosis

  1. Toe Fracture
  2. Metatarsal Fracture
  3. Turf Toe
  4. Ligament or Tendon Injury
  5. Nerve entrapment
  6. Sesamoiditis
    1. Sesamoid bone edema secondary to repeated stress
    2. Cortical disruption (Fracture) is absent

IX. Management

  1. Mild cases
    1. Buddy taping or stiff-soled shoe
    2. Arch supports (prefabricated or custom)
  2. Moderate cases
    1. Short Leg Walking Cast or CAM Boot for 4 weeks
    2. Consider initial non-weight bearing initially
    3. Follow-up with Metatarsal supports after Casting
  3. Refractory pain after immobilization
    1. Local Corticosteroid Injection (or Platelet-rich plasma injection)
    2. Orthopedic referral for sesamoid resection (uncommon)

X. Complications

  1. First MTP Degenerative Joint Disease
  2. Nonunion Fracture

XI. Course

  1. Anticipate persistent symptoms for up to 6 months

XII. References

  1. Delee (2003) Orthopaedic Sports Med, p. 2512-14
  2. Marx (2002) Rosen's Emergency Medicine, p. 731
  3. Riveros and Valiveti (2025) Crit Dec Emerg Med 39(9): 20-1

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