Great Toe





- dancers

- athletes




Hyperdorsiflexion of the MTPJ




MT head dislocates plantar

- may buttonhole through capsule

- can prevent closed reduction


Blocks to Reduction


1.  Sesamoids

2.  Conjoint tendon

3.  Intersesamoid Ligament




Closed Reduction


Open Reduction


Dorsal Approach

- protect dorsal superficial nerve

- divide capsule medial to EHL

- may need to divide intersesamoid ligament

- may need to divide adductor hallucis




Hallux Rigidus



Painful restriction of dorsiflexion of the great toe 

- secondary to degenerative changes in MTPJ

- initially pain and synovitis

- osteophytes don't form medially or on plantar aspect




Two peaks

1.  Adolescence F > M

2.  Middle Age M > F




Often Idiopathic




- hyperextension injuries



- pronated foot

- abnormally long 1st MT

- pes planus

- DF 1st ray



- gout


- inflammatory arthropathy




Pain on walking

- especially slopes & rough ground

- pain may become continuous



- compression of dorsomedial cutaneous nerve




Shoe shows excessive lateral wear

- toe off on lateral border 

- patient avoids dorsiflexion



- hallux is usually straight

- MTPJ is enlarged



- synovial thickening

- palpable dorsomedial osteophyte & bunion 

- altered sensation dorsal toe / due to tethering of dorsomedial nerve by osteophytes



- DF restricted & painful N = 90°

- PF often reduced and painful N = 30°




Changes of osteoarthritis

- dorsomedial osteophyte

- joint space narrowing


Great Toe Dorsal OsteophyteHallux Rigidus Dorsal Osteophyte




Non Operative




Education & Reassurance



- initially stiff soled shoes

- rockerbottom sole

- high toe box







1.  Moberg Osteotomy



- young patient with mild OA & > 30° PF



- dorsal closing wedge osteotomy of P1 

- converts PF range into functional DF


2.   Cheilectomy


Mann 1988 JBJS



- removal of dorsal osteophytes

- increase painless DF range (average 20°)


Great Toe Cheilectomy



- for adults with minimal degenerative changes

- normal joint space in plantar half MTPJ



- recurrence of pain



- dorsal incision over MTPJ

- joint incised either side EHL

- synovectomy

- remove ~ 1/3 of dorsal MT head

- remove osteophytes from base of P1

- need DF of ~ 90°

- stiff shoe till ROS

- then flexible sole and ROM exercise


3.  Arthrodesis


Great Toe MTPJ OAGreat Toe MTPJ Fusion APGreat Toe MTPJ Fusion Lateral



- adults with significant degenerative changes



- lateral transfer metatarsalgia


- malposition

- limitation of footwear type

- non-union



- dorsomedial approach

- protect dorsal cutaneous nerve

- mobilise EHL laterally and open capsule

- divide collaterals

- free P1 of soft tissue attachments

- 15° valgus

- 15° DF relative to plantar surface / 20 - 25° relative to metatarsal shaft

- dorsal plate / crossed screws



- 30% develop asymptomatic OA IPJ


Hallux Rigidus Fusion 2 screws APHallux Rigidus Fusion 2 screws Lateral


4.  Interpositional Arthroplasty



- severe OA & moderate demand

- minimal bone resection



- imbricate dorsal & volar capsule into joint space


5.  Swanson Arthroplasty



- adults with low demands



- breakage

- silicon synovitis

- very difficult to salvage


6.  Keller's Procedure



- for elderly with low demands



- lose windlass mechanism

- transfer metatarsalgia

- cosmetically poor

- drifts into both DF & valgus / Cock Up deformity



Hallux Valgus


DefinitionHallux Valgus Severe



- medial prominence of head of 1st MT


Hallux Valgus

- medial deviation 1st MT

- lateral deviation of great toe




Metatarsal head

- has 2 grooves separating ridge (cristae)



- in each tendon of FHB

- sesamoids attach to P1

- no attachment to MT head

- sesamoid ligaments attach to sesamoids and plantar plate

- FHL passes plantar to the plate & between the sesamoids


Plantar plate

- formed by

- FHB / Abd. Hall / Add. Hall / Plantar aponeurosis /  capsule


Sesamoids and plantar plate stabilised

- abductor hallucis (medial)

- adductor hallucis & trans metatarsal ligament (lateral)

- insert into sesamoids & Base P1

- no muscles insert into head MT


Collateral ligaments

- from head of MT to base of P1

- insert into sesamoids




Great Toe provides stability to the medial aspect of the foot


Windlass mechanism of plantar aponeurosis

- plantar aponeurosis arises from tubercle of calcaneum

- medial slip inserts into base of proximal phalanx via sesamoids

- as body passes over foot, P1 forced into DF & slides over MT head

- plantar aponeurosis winds around MT head & plantarflexes the 1st MT

- creates arch


In hallux valgus, windlass is less effective

- results in transfer of weight to lateral aspect of foot

- especially second MT head


Blood Supply


3 main

- 1st dorsal and plantar metatarsal artery

- superficial branch of medial plantar artery




Medial plantar artery

- remains plantar to the MT until the level of the neck when it runs obliquely dorsally

- divides into the medial cervical branch, and the medial sesamoid branch




First plantar MT artery

- is formed by the deep plantar arch and a perforating branch from the DPA

- runs distally in the 1st MT space

- nutrient artery to neck (variable)

- cervico-sesamoid branch (constant)


Lateral Cervical branch

- enters plantar surface at base of neck

- supply major part of head

- care in not stripping under the neck to preserve the cervical branch



- small branch from DPA

- penetrates the dorso-lateral capsule near margin of  articular cartilage

- not big enough to provide sole supply

- can be sacrificed if needed




Great toe

- lateral deviation of the great toe  (HVA > 15o)

- medial deviation of the first metatarsal  (IMA > 9o)

- +/- subluxation of the first MTPJ

- hallux pronation

- prominent mediation eminence

- sesamoid rotation / uncovering


Lesser toes

- overriding of the second toe

- metatarsalgia

- lesser toe hammer & claw




Two ages of presentation


1.  Adolescent form

- usually bilateral


2.  Adult form ~ 50's

- strongly familial

- positive FHx in 2/3

- F > M

- F:M = 9:1 in those needing operations




Likely multifactorial


1.  Shoe Wearing



- more women are affected

- women's shoes are tight-toed

- unshod 2% vs 33% shod

- unshod toes separate on weight bearing

- in shoes, toes crowded & hallux abducted


2.  Hereditary

- usually strong FHx

- tend to present earlier

- AD with incomplete penetrance

- made worse by female's shoe wear


3.  Generalised Ligamentous Laxity

- splaying of forefoot

- excessive mobility of 1st TMT

- laxity of medial capsule of MTPJ


4.  Anatomical factors


Metatarsus Primus Varus

- associated with HV

- especially adolescent variety


Metatarsus Varus


1st MT

- long / short

- hyper pronated


2nd Toe amputation

- loss of lateral support for great toe



- rounded joint



- hypermobile

- medially slanted




Short achilles tendon


5.  Pathological Conditions


Rheumatoid arthritis

- leads to loss of capsular support

- RA best treated with fusion


Neurological conditions

- CP best treated with fusion




A.  Congruent MTP joint



- increased DMAA 

- Hallux valgus interphalangeus



- enlarged medial eminence (bunion)

- pressure against shoe

- painful bursa or cutaneous nerve



- MTP joint usually stable & won't sublux

- can’t do distal soft tissue release

- will sublux a congruent joint


B.  Incongruent MTPJ


Hallux Valgus Incongruent Joint, ex


Subluxed MTPJ

- usually progressive



- starts with lateral pressure on great toe

- tight high heels

- P1 moves laterally



- PI moves laterally & puts pressure on MT head

- moves it medially, thus increasing intermetatarsal angle

- attenuation of medial joint capsule

- sesamoid sling held in place by ADDH & transverse metatarsal ligament

- MT head moves further medially / varus deformity

- slides off sesamoids


Final deformity

- appearance of lateral migration of sesamoids

- however sesamoids maintain constant distance from second MT

- lateral sesamoid lies beside MT head in intermetatarsal space

- ADDH pronates the great toe

- medial extensor hood / capsule stretched

- EHL & FHL comes to lie lateral to MTPJ

- finally, lateral capsular structures become contracted & the deformity becomes fixed


C.  Medial Eminence

- MT head changes occur

- groove or medial sagittal sulcus develops at medial border of articular cartilage


D.  Bunion

- callosity of skin + bursa


E.  Lesser Toes

- MTP less stable & weight transferred to MT 2 & 3 -> callosities

- great toe may drift beneath 2nd toe

- alternatively, 2nd toe may subluxate laterally

- lateral toes become crowded

- often develop claw or hammer deformity

- increased weight bearing through middle MT heads may lead to metatarsalgia

- worse with clawing of lesser toes





- over medial eminence (75%)

- metatarsalgia under lesser toes

- degeneration of sesamoid joint

- dorsal aspect osteophytes / rigidus


Shoe problems

- wide foot

- difficulty fitting shoes


Secondary deformity of lesser toes

- especially hammer deformity of the second toe

- rubbing of the PIPJ on shoe


Cosmetic appearance




Hallux Valgus Clinical



- bunion

- HV

- clawing / hammer toes


Assess ROM ankle and STJ

- tight T Achilles


Look at wear patterns on foot

- callosities under 2/3 MT head



- tender bunion

- painful MTJP

- correctable / ROM correctable

- pain over sesamoids



- hypermobility

- > 9mm abnormal


Lesser toes

- deformity / correctable


Neurovascular examination


Weight Bearing AP X-ray


1.  Hallux Valgus Angle / MTPA

- metatarso-phalangeal angle

- normal < 15o


Hallux Valgus MTPA > 40


2.  Intermetatarsal angle/ IMA

- normal < 9o


Hallux Valgus Intermetatarsal Angle > 20 degrees


3.  Congruence

- place dots

- medial & lateral edges of the articular surfaces of the MT head & P1 base

- assess to see if line up / joint congruent


Hallux valgus Incongruent Joint


4. Interphalangeal angle

- normal is <10°

- identify hallux interphalangeus


5.  DMAA

- distal metatarsal articular angle

- normal < 6o


Hallux Valgus Increased DMAA


5.  Sesamoid subluxation

- amount of lateral sesamoid uncovered by MT

- medial sesamoid should not cross midline axis of MT


Hallux Valgus Lateral Sesamoid Uncovered




7.  Size of the medial eminence

- amount of MT head medial to the line along the medial border of the MT


8.  TMT Angle

- medial sloping


Hallux Valgus Medial Sloping TMTJ


Mann Classification  


1.  Congruent


2.  Incongruent


A.  Mild


MTPA < 30°

IMA < 15°

Lateral sesamoid < 50% uncovered


Hallux Valgus Mild


B. Moderate


MTPA 30 - 40°

IMTA 15 - 20o

Lateral sesamoid 50 - 75% uncovered


C. Severe


MTPA > 40°

IMTA > 20°

Lateral sesamoid > 75% uncovered


Hallux Valgus Severe Unilateral


3.  Degenerative


Hallux Valgus Severe Degenerative





Education regarding shoe wear

- extra wide / large toe box



- longitudinal arch support

- pre MT dome for metatarsalgia

- podiatry to attend to callosities


Toe spacers








1.  Continued pain and discomfort

2.  Difficulties with shoe wear

- split size shoe requirements 

- difficulty fitting shoes

- only 60% wear "fashionable" shoe post-op

3.  Deformity of lesser toes

4.  Skin problems

5.  Cosmetic appearance – relative indication




Poor peripheral arterial circulation

Current sepsis

Uncontrolled diabetes

Peripheral neuropathy (relative)




1. Correction of the hallux valgus and intermetarsal angles 

2. Creation of a congruent MTP joint

3. Sesamoid realignment

4. Removal of the medial eminence

5. Retention of functional range of motion of the MTPJ

6. Maintenance of normal weight bearing mechanics of foot


Surgical Options




1. DMAA  < 15°

- treat hallux interphalangeus

- Akin with exostectomy


2. DMAA > 15°

- Chevron with closing wedge





- Chevron

- DSTP (Distal Soft Tissue Procedure) +/- proximal osteotomy



- DSTP & proximal osteotomy

- Scarf



- DSTP & proximal osteotomy

- arthrodesis




Mild to Moderate / Low demand

- arthroplasty



- arthrodesis


Hypermobile TMTJ

- fusion (Lapidus) & DSTP


Surgical Procedures


1.  Chevron


Hallux Valgus ChevronGreat Toe Chevron



- incongruent joint

- HVA < 30o / IMA < 15o

- patient < 60 years




Avoid lateral release = AVN 40%


Approach to Hallux Valgus


Dorsomedial approach in internervous plane

- don't go directly medial as will get sensitive scar

- protect dorsal sensory nerve

- distally based "V" capsular flap

- expose MTP joint



- remove medial eminence with saw

- leave 1- 2 mm medial to medial sulcus

- otherwise risk hallux varus


60° osteotomy apex distal

- longer plantar limb to avoid sesamoids and inferior joint surface

- apex 1 cm from articular surface

- translate 5mm

- 1mm displacement corrects IM angle 1º

- can perform medial closing wedge to correct DMMA



- not always necessary

- sutures / k wire / screw



- imbricate capsule

- advance to tighten medially


Second toe releases as needed


Post op

- bandage / POP to maintain correction

- check wound at 1 week

- bunion boot / heel walk

- toe spacer

- 6/52


Hallux Valgus Toe Spacer




GE 75% if IMA >12° 

GE 95% if IMA <12°




AVN is rare

- ensure apex 8-10 mm from articular surface

- avoid DSTP


2.  Distal Soft Tissue Procedure


Hallux Valgus Pre DSTPHallux Valgus Post DSTP


Modified McBride

- release of tight lateral structures (ADDH, lateral capsule, transverse MT ligament)

- medial exostectomy (just medial to sagittal sulcus)

- medial capsular plication


(Modification: no longer excise sesamoid)



- mild HV with incongruent joint

- severe HV when combined with proximal osteotomy




1.  Dorsomedial approach

- protect nerve

- V shaped capsulotomy

- remove medial prominence


2.  Incision first web space

- protect branches of DPN

- insert lamina spreader

- release ADD hallucis at P1

- cut capsule between sesamoid and MT

- divide transverse MT ligament



92% good results




Nerve injury

- plantar cutaneous nerve


Hallux varus

- from releasing lateral FHB from sesamoid


3.  Proximal Osteotomy + DSTP



- severe HV

- correct IMA with osteotomy

- correct HVA with DSTP



- in combination with DSTP

- GE 90 %



- crescentertic

- opening wedge (lengthens)

- closing wedge (shortens)


Opening wedge

- extend medial incision

- incomplete ostetomy with saw at base MT

- use bone from bunionectomy to fill gap

- fixation with small plate


4.  Scarf



- moderate HV

- see separate technique

- technically challenging but good results


5.  Akin



- congruent joint

- DMAA < 15o

- hallux interphalangeus > 10o

- residual HV after other procedures



- medial closing wedge osteotomy of P1

- combine with cheilectomy


6.  Keller Procedure



- resection 1/3 of proximal phalanx

- should use pin to stop cock up deformity & to stiffen joint



- housebound / non ambulator

- elderly

- salvage

- marginal circulation - DM / PVD

- hallux rigidus if cheilectomy or arthrodesis contra-indicated



- instability / cock up deformity

- transfer metatarsalgia (in young)



- 80% good results


7.  Arthrodesis



- hallux valgus with arthritis

- severe hallux valgus

- neuromuscular disease i.e. cerebral palsy

- RA

- salvage procedure for failed procedures



- 15º valgus

- DF 10º relative to plantar aspect of foot

- DF 30° relative to ray



- dorsomedial approach

- release EHB / mobilise EHL / release collaterals

- Coughlin male and female reamers

- secure with cross screws or plate


Hallux Valgus Arthrodesis


8. Lapidus Procedure


Hallux Valgus SevereHallux Valgus Proximal Osteotomy and Lapidus



- TMTJ hypermobility

- fusion TMTJ



- difficult to achieve union

- difficult to get position correct


Joint multiplanar

- malrotation poorly tolerated

- shortens medial column

- can get metatarsalgia



- slight plantar flexion and lateral deviation


Lapidus APLapidus Lateral


Complications of Surgery


Transfer Metatarsalgia



- incorrect surgery

- poorly performed surgery

- high risk groups i.e. adolescent


Nerve injury

- dorsal and plantar cutaneous nerve


Cock up Toe



- post Keller’s




Arthrodesis MP joint

- shorten if don't use graft

- fusion rate 95% (BG) vs 70% (no BG)


Hallux Varus



- excessive medial resection

- resection of fibular sesamoid

- excessive lateral release or medial plication



- not always painful

- cosmetically unacceptable

- difficulties with shoe wear

- cockup deformity

- with time stiffens in extension & medial deviation



- soft, well fitting shoe

- arthrodesis

- soft tissue reconstruction


EHL Reconstruction           

- lateral two thirds of the tendon removed from its insertion

- detached distally, passed under transverse ligament

- inserted into proximal phalanx




Rarely seen in Chevron

- due to disruption of volar blood supply


Great Toe AVN Post Chevron



- arthrodesis / excise avascular fragment and shorten toe

Scarf Osteotomy



A.  Longitudinal Cut

- plantar proximal / dorsal distally

- ends up being parallel to sole

- leave strong plantar portion of head to prevent dorsiflexion

- mark centre of head

- distally to a point 2mm prox and 3mm above the centre of the head


B.  Transverse cuts

- plantar proximal / dorsal distal

- angle of 45o with the long cut

- directed slightly proximal (10-15o) to aid displacement




A. Transverse plane

- Primary direction of displacement

- can be up to ¾ of the surface as the strong lateral strut is preserved

- lateral rotation should be avoided as it increases the DMAA

- medial rotation can be used (to improve DMAA) but limits the amount of lateral displacement


B. Frontal plane

-  Lowering of the 1st MT head is achieved via the obliquity of the transverse cut

-  It will act to relieve metatarsalgia


C. Sagittal plane

- Lengthening can be done but tends to increase soft tissue tension and lead to stiffness

- shortening can be readily achieved by

- increasing the obliquity of the transverse cuts (max shortening 3mm)

- resecting ends of prox  / distal fragments (doesn’t elevate head as II to sole)




Cannulated screws over K wires


A. Distal

- start lateral where the bone is string and allows medial resection

- aim obliquely into the MT head

- screw to end 2mm prox to cartilage


B. Proximal

- important to respect the lateral part of the fragment to avoid fracture

- aim transverse from dorso-medial to plantar-lateral


The corner is then taken off the proximal fragment 

- rounded with rongeurs where bunion has been sliced off



Ingrown Toe Nail





Improper nail trimming

Tight shoes & socks

Poor hygiene

Repetitive trauma to distal toe

Curved nail bed in elderly




1.  Inflammation

- painful irritation about embedded nail plate in lateral groove


2.  Infection

- overt infection with granuloma & discharge 

- starts as serous discharge then purulent


3.  Granulation

- stage 1 & 2 + chronic changes

- hypertrophy of lateral wall

- growth of epithelium over chronic granulation tissue 




Stage 1 

- non-operative


Stage 2 

- oral ABx then non-operative

- if fails partial nail avulsion


Stage 3 

- often requires partial nail matrix ablation


Non Operative

- warm saline soaks x2 /day

- pledget under nail corner

- cleaning of lateral groove

- nail will grow 2 mm /month

- aim for nail plate that protrudes distal to hyponychium




1.  Wedge resection



- remove lateral part of nail

- partial ablation of nail matrix

- debulk tissue in lateral fold


Post op

- non adherent dressings 48/24 then warm soaks

- open toe box shoe 10/7

- 3-4 weeks before normal shoes again



- recurrence spicules nail plate 

- 5%


2.  Zadek's



- removal of nail plate 

- removal of entire germinal nail matrix proximal to lunule


3.  Terminal Symes procedure



- amputation of the distal half of the distal phalanx

- good for dystrophic and mycotic nails

- toe end appears bulbous




Juvenile Hallux Valgus



More common in girls

High incidence of positive family history (75%)


Can be associated with mild CP




Juvenile Hallux Valgus


Congruent joint

- 50% compared with 9% in adult HV


Metatarsus primus varus

- increased IM angle

- often the primary deformity


Epiphyses usually still open


Oblique first TMTJ Angle


Ligamentous Laxity


Difference from Adult HV


Less severe

- no arthrosis

- sesamoid subluxation & pronation less common than in adult

- medial eminence not as prominent

- HVA not as big a contributor




Ligamentous laxity


T Achilles tightness


TMTJ hypermobility


Neurological examination




Normal Angles

- HV < 15o

- IMA < 9o

- DMAA < 10o


Often DMAA increased






Delay any surgery until

- adolescence

- physis closed (but not CI if open)


Well fitting shoes


Flexible flat foot may benefit from medial arch support





- reduce DMAA

- reduce IMA


Congruent joint 

- less likely to progress (therefore treat conservatively)

- requires extra-articular realignment




1.  Double or triple osteotomies


A.  Akin / proximal phalangeal osteotomy

- corrects interphalangeal angle


B.  Chevron biplanar distal metatarsal osteotomy

- adjust DMAA by adding closing wedge osteotomy


C.  Proximal metatarsal osteotomy

- further corrects IMA


2.  Hypermobile TMTJ common

- Lapidus procedure


Hallux Valgus Lapidus Procedure


3.  1st Cuneiform Opening Wedge Osteotomy

- severe IM angle with open 1st metatarsal epiphysis

- marked M-C joint obliquity with high IM angle

- opening wedge (iliac crest graft)




20% recurrence rate

- failure to correct IMA


Hallux varus 

- split extensor hallucis longus transfer



- rare even in combined distal procedure







Fungal infection of the nail




Toenail affected 4x more common than fingernail

Prevalence has increased x 4 in last 2 decades




Dermatophytes most common cause


99% T rubrum & T mentagrophytes

- destroy nail by chemical or enzymatic process





- keratin of hyponychium is infected by the dermatophyte



- involves nail bed & nail plate

- initially invades ventral plate which arises from nail bed

- intermediate plate has soft keratin & can become involved

- dorsal nail plate rarely involved




Usually cosmetic problem only

- may become painful




Microscopy of nail scrapings & culture studies

-> hyphae

- can culture if necessary






Debride & remove part or all of nail


Topical agents less effective than systemic because don't target matrix


Oral antifungals 

- griseofulvin & ketoconazole (need up to 1 year of treatment)

- terbinafine (Lamasil) & itraconazole (Sporanox) 

- more effective with shorter treatment (3-6m)

- remain in the nail for 6 months





Terminal Syme amputation





3 Sesamoids may be present in great toe

- 2 almost always present on plantar aspect of MTPJ

- 1 may be present on plantar aspect of IPJ


MTPJ sesamoids most important

- embedded in FHB tendons

- held together by intersesamoid ligament & plantar plate

- each side of crista / inter-sesamoid ridge

- articulate with plantar facets of 1st MT


Tibial usually larger than fibula


Tibial more impacted in weight bearing than fibula

- higher incidence traumatic injury to tibial




- Adductor hallucis

- Abductor hallucis

- Plantar plate

- Intersesamoid Ligament

- Plantar aponeurosis



- Proximal to MT head in stance

- Pulled under MT head with DF / toe off



- between 7-10 years

- often multiple centers 

- may result in bipartite / tripartite appearance



- fibular rare

- tibial bipartite in ~ 10% 

- bilateral in ~ 25% of these

- congenital absence - one or both


Bipartite Sesamoid


Blood Supply


Type A 50% medial plantar artery and plantar arch

Type B 25% plantar arch

Type C 25% medial plantar artery


Increased risk of AVN if only single vessel into sesamoid

- which is seen in Type C more commonly than B



- absorb weight bearing pressure

- reduce friction

- protect tendons

- act as fulcrum to inc mechanical force of FHB

- Sesamoids and Collats provide medial / lateral stability of 1st MTPJ




Do not always present with symptoms directly referable to sesamoids

- generalized pain around Hallux

- pain after sudden pop or snap after running


Pain as hallux extends in terminal part of stance phase


Neuralgic symptoms or numbness if digital nerve compressed 




Local tenderness

Decreased strength on PF

Pain on passive DF

Loss of active & passive DF


Cavus foot

- plantar flexed 1st ray 

- excess axial load on sesamoid




Standard lateral not very useful

- AP, medial oblique, lat oblique, axial


Bone scan 


Projection important to differentiate sesamoids from MTPJ

- may be obscured by AP scan

- PA or oblique with Collimation useful for DDx

- caution with increased uptake in ~25% of asymptomatic patients

- marked difference to contralateral side significant




Useful for Osteomyelitis




Useful for post-traumatic changes 

- compared with contralateral side




1.  Fracture


Difficult to differentiate from symptomatic multipartite sesamoid

- especially if fracture through bipartite 

- comparison X-ray with contralateral foot 

- MRI & bone scan with pin hole collimation useful


 Fractured SesamoidSesamoid Fracture CT


Non operative management

- initial treatment

- orthosis / dancer's pad / cast / MT bar

- especially stress fracture



- excision of most comminuted fragment or entire sesamoid

- preferred over bone graft in most cases

- consider graft for athletes


2.  Osteochondritis



- osteonecrosis with regeneration & calcification may be present

- may be enlarged / deformed / sclerotic with mottling / fragmentation


3.  Infection


Rare except diabetic neuropathy

- Pseudomonas relatively common 


4.  Sesamoiditis


Repetitive trauma especially teens / young adults

- Inflammation & bursal thickening may be present


5.  Osteoarthritis


May be in conjunction with MTPJ OA / RA / Gout




Stiff soled or rocker bottom shoe + MT pad



- may decreases pain

- Don't remove both

- leads to clawing of hallux


6.  Intractable Plantar Keratoses


Usually caused by

- sesamoid with plantar located osseous prominence

- plantarflexed first metatarsus / cavus




Intractable lesions

- sesamoid shaving or resection

- avoid shaving if 1st MT is plantarflexed

- consider basilar dorsiflexion osteotomy


7.  Nerve Impingement


Impingement of medial branch plantar digital nerve on medial sesamoid






1.  Never excise both 

- high incidence of Hallux Valgus or Cock Up deformity

2.  Never make incision directly over sesamoid

3.  Always repair adductor if excising lateral sesamoid


Produce mechanical defect in FHB unit

- can excise up to 2/3 of either without disturbing ligamentous attachments

- may relieve pain without disrupting FHB mechanism




Tibial sesamoid excision

- 3cm plantar medial incision

- Medial branch plantar digital nerve identified & retracted

- Locate sesamoid by palpation

- Flex hallux 20-30o & retract FHL

- Incise inter-sesamoid ligament & pull sesamoid medial

- Shell out from capsule & plantar plate with knife

- Imbricate capsule


Tibial sesamoid shaving

- Plantar medial approach

- Excise plantar 1/2 with microsagittal saw

- Smooth with rongeur





- either dorsal or plantar approach

- dorsal demanding due to depth

- plantar - NV bundle & FHL to negotiate  


Dorsal incision 

- from 2-3 cm proximal to web space

- Identify & protect branch SPN

- Interval between Adductor Hallucis & joint capsule opened

- Tendon of Add Hallucis reflected from lateral sesamoid

- Grasp sesamoid & divide inter-sesamoid ligament

- Release proximal & distal & excise

- repair adductor

- Close skin 


Plantar incision

- Flex hallux

- 4cm incision between MT 1 & 2

- Retract NV bundle either lateral or medial

- Locate FHL & open pulley over it

- Flex hallux to relax FHL & retract medially

- Divide inter-sesamoid ligament

- Excise proximally & distally

- Reattach cuff of FHB

- Consider oblique wire across MTPJ




Cock up toe

Hallux valgus or varus

Nerve injury

Fat pad disruption

Painful plantar scar if plantar incision

Turf Toe



Hyper-dorsiflexion injury to 1st MTP joint




Grade 1 - Mild sprain



- minimal swelling / ecchymosis



- return to play immediately



Grade 2 Partial tear plantar plate



- tender / swelling / ecchymosis



- return to sport 1-2 weeks

- taping toe to prevent hyper-extension

- stiff soled shoes


Grade 3 complete tear plantar plate



- marked pain / swelling / ecchymosis / marked decrease ROM

- +/- sesamoid fracture / disruption of FHB



- return to sport 3-6 weeks

- surgical removal of loose bodies



- see proximal displacement of sesamoids

- require operative repair of plantar plate