Vol. 17A, No. 5 September I992
Thumb interphalangeal joint sesamoiditis
cleation of a problem curative treatment.
of the sesamoid articular surface and synovitis at its condylar articulation. The bone was removed. The IP joint was normal. Pathologic examination of the specimen was positive only for degenerative changes. The patient had immediate postoperative relief of pain and was able to resume all activities she had performed before the onset of symptoms. This symptomfree state has persisted for 18 months.
sesamoid
is the definitive
and
REFERENCES 1. Parks BJ, Hamfin C. Chronic sesamoiditis of the thumb: pathomechanics and treatment. J HAND SURG 1986: 1 lA:237-40. 2. Trumble TE, Watson HK. Posttraumatic sesamoid arthritis of the metacarpophalangeal joint of the thumb. J HAND SURG 1985;10A:94-100. 3. Wood V. The sesamoid bones of the hand and their pathology. J HAND SURG 1984;9B:261-4. 4. Resnick D, Niwayama G, Feingold ML. The sesarnoid bones of the hands and feet: participators in arthritis. Radiology 1977;123:57-62. 5. Hansen CA, Peterson TH. Fracture of the thumb sesamoid bones. J HAND SURG 1987;12A:269-70.
Discussion Five sesamoid bones are commonly present in the hand-two at the thumb MP joint, one at the thumb IP joint, and one each at the index and small finger MP joints.3 The radial sesamoid of the thumb MP joint is the one most commonly subject to degenerative and arthritic changes, as noted by Trumble and Watson’ in a cadaver study. There is general agreement that enu-
Fifth digit sesamoid fracture with tenosynovitis Yuji Inada, Akihiro
MD,
Fukui,
DMedSc, MD,
Susumu
DMedSc,
Tam&,
F ractures
of sesamoid bones in the hand and most of the reported ones have occurred in the thumb.‘.’ These fractures seldom require surgical treatment unless there is disabling pain. We recently resected a fractured small finger sesamoid because of persistent swelling and pain.
From the Department of Orthopedic Surgery, Nara Medical Univers~ty, Kashihara, Nara, Japan, and the Division of Orthopedic Surgely, Ohmiwa Hospital, Sakurai, Nara, Japan. Sept. 27, 1991; accepted
DMedSc,
Kouichi
Kawanishi,
MD,
and
Nara, Japan
are uncommon,
Received for publication Dec. 4, 1991.
MD,
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Case report A 39-year-old housekeeper sustained a hyperabduction injury when her left small finger when was grabbed by a child. She had swelling and tenderness around the fifth metacarpophalangeal (MP) joint. An initial tangential x-ray film was normal, but a CT scan clearly showed the horizontal fracture (Fig. 1). Initial treatment involved use of a splint for 3 weeks, and this seemed to relieve the problem. Six months later the patient returned with recurrent pain and swelling, and a tomogram in the sagittal plane showed the nonunion (Fig. 2). At operation the synovium in the flexor tendon sheath was inflamed. Part of the Al pulley was resected to gain access to the fracture, which had disrupted through the floor of the sheath (Fig. 3). The bone was totally resected. The patient did well postoperatively and was free of symptoms with normal function 1 year after the surgery.
Cadaver
study
Reprint requests: Yuji Inada, MD, DMedSc, Orthopedic Room 3 14, Hospital for Special Surgery. York, NY 10021. 3/l/35806
Research, 535 East 70th St., New
We studied 20 small fingers by x-ray and dissected bones in the area of the fifth MP joint. One of the 16 had two sesamoid bones. The
the 16 that had sesamoid
915
916
The Journal of HAND SURGERY
Inada et al.
Fig. 1. CT scan showing irregularity of sesamoid bone in small finger and horizontal fracture line. Displacement
was not seen at the first injury. Arrow shows level of the fracture.
Fig. 2. Tomogram on sagittal plane showing nonunion of sesamoid bone 6 months later. The anterior fragment was slightly displaced.
Fig. 3. After opening of the inflamed tendon sheath, it was ruptured by part of upper fragment of sesamoid bone. It was easy to isolate the anterior fragment from the posterior fragment.
Vol. 17A, No. 5 September I992
THEJOURNALOFHANDSURGERY
bones ranged from 2 x 2 x 2 mm to5 x 5 x 3 mm in size, and cystic changes were seen in one of them. All of the single sesamoids lay under both the MP joint capsule and the flexor tendon sheath.
4. 5.
Discussion 6.
According to various reports, fifth digit sesamoid bones occur with a frequency of between 40% and 82%.‘-13 The sesamoid forms part of complicated palmar plate, as JosephI and Kaplan” have observed. Their function is probably to modify pressure, diminish friction, and alter the direction of pull of the flexor tendons. We think that the mechanism of injury in our case was pressure of the flexor tendons on the bone when the digit was hyperabducted. Wood’ indicated that in his case it was due to hyperextension. Whatever the mechanism of injury, CT scans or tomograms can visualize the bone well, and, if symptoms persist, the sesamoid should be totally resected.
7. 8. 9.
Sesamoid fracture of the thumb. Br J Radio1 1983;56:485. Jones RP, Leach RE. Fracture of the ulnar sesamoid bone of the thumb. Am J Sports Med 1980;8:446-7. Wood VE. The sesamoid bones of the hand and their pathology. J HAND SURG 1984;9B:261-4. Bell MJ, McMurtry RY, Rubenstein J. Fracture of the ulnar sesamoid of the metacarpophalangeal joint of the thumb: an arthrographic study. J HAND SURG 1985;lOB:379-81. Hansen CA, Peterson TH. Fracture of the thumb sesamoid bones. J HAND SURG 1987;12A:269-70. Pfitzer W. Die Sesambeine des Menschlichen Korpers. Morph01 Arbeiten Schwalbe 1892;517-762. Bizarro AH. On sesamoid and supernumerary bones of the limbs. J Anat 1921;55:256-68.
10. Kassatkin S. Die Sesambine-der Hand und des Fusses des Menshe. Z Anat Entwicklungs 1934;102:635-54. 11. Hunbay CA. Sesamoid bones of the hands and feet. Am J Roentgen01 1949;61:493-505. 12. Goldberg I. Nathan H. Anatomy and pathology of the sesamoid bones. Int Orthop 1987;ll: 141-7. 13. Joseph J. The sesamoid bones of the hand at the time of fusion of the epiphyses of the thumb. J Anat 195 1;85:23041. 14. Kaplan EB. Functional and surgical anatomy of the hand. 2nd ed. Philadelphia: JB Lippincott 1965:90-4.
REFERENCES Streatfield T, Griffiths HF. Fracture of a sesamoid bone. Lancet 1934;1:1117. Sindberg SE. Fracture of a sesamoid of thumb. J Bone Joint Surg 1940;22B:445-5. Clark P. Braunstein EM, Weissman BN, Sosman JL.
Salvage for failed implant arthroplasty of the wrist We have had to revise 19 wrist arthroplasties-seven total wrist arthroplasties.
silicone implants and 12 metal-on-plastic
Each of the seven silicone implants
was successfully
revised in one
operation; the four fusions and three total wrist implants were functioning 6 or more years after surgery.
Nineteen
operations
were needed to revise the total wrist implants.
because of loosening, six had become unbalanced, prostheses eventually
Four had failed
and two had become infected. All of the loose
required fusion. Four of the unbalanced
wrists were rebalanced,
but two
of these patients have pain; the other two cases required fusion. One infected wrist required fusion, and one is stable with an implant.
(J HAND SURG 1992;17A:917-23.)
Donald C. Ferlic, MD, Denver, Cob., Mack L. Clayton, MD, Denver, Colo.
From the University of Colorado Health Sciences Center, Denver, Colo., the Denver Orthopedic Clinic, Denver, Colo., and Littleton Orthopaedic Associates, Littleton, Colo. Received for publication Nov. 5, 1991; accepted in revised form March 17. 1992.
Susan N. Jolly, MD, Littleton,
Cola., and
One or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Donald C. Ferlic, MD, Denver Orthopedic Clinic, 2005 Franklin St., Fifth Floor. Denver, CO 80205. 311138436
917
Thumb interphalangeal joint sesamoiditis
cleation of a problem curative treatment.
of the sesamoid articular surface and synovitis at its condylar articulation. The bone was removed. The IP joint was normal. Pathologic examination of the specimen was positive only for degenerative changes. The patient had immediate postoperative relief of pain and was able to resume all activities she had performed before the onset of symptoms. This symptomfree state has persisted for 18 months.
sesamoid
is the definitive
and
REFERENCES 1. Parks BJ, Hamfin C. Chronic sesamoiditis of the thumb: pathomechanics and treatment. J HAND SURG 1986: 1 lA:237-40. 2. Trumble TE, Watson HK. Posttraumatic sesamoid arthritis of the metacarpophalangeal joint of the thumb. J HAND SURG 1985;10A:94-100. 3. Wood V. The sesamoid bones of the hand and their pathology. J HAND SURG 1984;9B:261-4. 4. Resnick D, Niwayama G, Feingold ML. The sesarnoid bones of the hands and feet: participators in arthritis. Radiology 1977;123:57-62. 5. Hansen CA, Peterson TH. Fracture of the thumb sesamoid bones. J HAND SURG 1987;12A:269-70.
Discussion Five sesamoid bones are commonly present in the hand-two at the thumb MP joint, one at the thumb IP joint, and one each at the index and small finger MP joints.3 The radial sesamoid of the thumb MP joint is the one most commonly subject to degenerative and arthritic changes, as noted by Trumble and Watson’ in a cadaver study. There is general agreement that enu-
Fifth digit sesamoid fracture with tenosynovitis Yuji Inada, Akihiro
MD,
Fukui,
DMedSc, MD,
Susumu
DMedSc,
Tam&,
F ractures
of sesamoid bones in the hand and most of the reported ones have occurred in the thumb.‘.’ These fractures seldom require surgical treatment unless there is disabling pain. We recently resected a fractured small finger sesamoid because of persistent swelling and pain.
From the Department of Orthopedic Surgery, Nara Medical Univers~ty, Kashihara, Nara, Japan, and the Division of Orthopedic Surgely, Ohmiwa Hospital, Sakurai, Nara, Japan. Sept. 27, 1991; accepted
DMedSc,
Kouichi
Kawanishi,
MD,
and
Nara, Japan
are uncommon,
Received for publication Dec. 4, 1991.
MD,
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Case report A 39-year-old housekeeper sustained a hyperabduction injury when her left small finger when was grabbed by a child. She had swelling and tenderness around the fifth metacarpophalangeal (MP) joint. An initial tangential x-ray film was normal, but a CT scan clearly showed the horizontal fracture (Fig. 1). Initial treatment involved use of a splint for 3 weeks, and this seemed to relieve the problem. Six months later the patient returned with recurrent pain and swelling, and a tomogram in the sagittal plane showed the nonunion (Fig. 2). At operation the synovium in the flexor tendon sheath was inflamed. Part of the Al pulley was resected to gain access to the fracture, which had disrupted through the floor of the sheath (Fig. 3). The bone was totally resected. The patient did well postoperatively and was free of symptoms with normal function 1 year after the surgery.
Cadaver
study
Reprint requests: Yuji Inada, MD, DMedSc, Orthopedic Room 3 14, Hospital for Special Surgery. York, NY 10021. 3/l/35806
Research, 535 East 70th St., New
We studied 20 small fingers by x-ray and dissected bones in the area of the fifth MP joint. One of the 16 had two sesamoid bones. The
the 16 that had sesamoid
915
916
The Journal of HAND SURGERY
Inada et al.
Fig. 1. CT scan showing irregularity of sesamoid bone in small finger and horizontal fracture line. Displacement
was not seen at the first injury. Arrow shows level of the fracture.
Fig. 2. Tomogram on sagittal plane showing nonunion of sesamoid bone 6 months later. The anterior fragment was slightly displaced.
Fig. 3. After opening of the inflamed tendon sheath, it was ruptured by part of upper fragment of sesamoid bone. It was easy to isolate the anterior fragment from the posterior fragment.
Vol. 17A, No. 5 September I992
THEJOURNALOFHANDSURGERY
bones ranged from 2 x 2 x 2 mm to5 x 5 x 3 mm in size, and cystic changes were seen in one of them. All of the single sesamoids lay under both the MP joint capsule and the flexor tendon sheath.
4. 5.
Discussion 6.
According to various reports, fifth digit sesamoid bones occur with a frequency of between 40% and 82%.‘-13 The sesamoid forms part of complicated palmar plate, as JosephI and Kaplan” have observed. Their function is probably to modify pressure, diminish friction, and alter the direction of pull of the flexor tendons. We think that the mechanism of injury in our case was pressure of the flexor tendons on the bone when the digit was hyperabducted. Wood’ indicated that in his case it was due to hyperextension. Whatever the mechanism of injury, CT scans or tomograms can visualize the bone well, and, if symptoms persist, the sesamoid should be totally resected.
7. 8. 9.
Sesamoid fracture of the thumb. Br J Radio1 1983;56:485. Jones RP, Leach RE. Fracture of the ulnar sesamoid bone of the thumb. Am J Sports Med 1980;8:446-7. Wood VE. The sesamoid bones of the hand and their pathology. J HAND SURG 1984;9B:261-4. Bell MJ, McMurtry RY, Rubenstein J. Fracture of the ulnar sesamoid of the metacarpophalangeal joint of the thumb: an arthrographic study. J HAND SURG 1985;lOB:379-81. Hansen CA, Peterson TH. Fracture of the thumb sesamoid bones. J HAND SURG 1987;12A:269-70. Pfitzer W. Die Sesambeine des Menschlichen Korpers. Morph01 Arbeiten Schwalbe 1892;517-762. Bizarro AH. On sesamoid and supernumerary bones of the limbs. J Anat 1921;55:256-68.
10. Kassatkin S. Die Sesambine-der Hand und des Fusses des Menshe. Z Anat Entwicklungs 1934;102:635-54. 11. Hunbay CA. Sesamoid bones of the hands and feet. Am J Roentgen01 1949;61:493-505. 12. Goldberg I. Nathan H. Anatomy and pathology of the sesamoid bones. Int Orthop 1987;ll: 141-7. 13. Joseph J. The sesamoid bones of the hand at the time of fusion of the epiphyses of the thumb. J Anat 195 1;85:23041. 14. Kaplan EB. Functional and surgical anatomy of the hand. 2nd ed. Philadelphia: JB Lippincott 1965:90-4.
REFERENCES Streatfield T, Griffiths HF. Fracture of a sesamoid bone. Lancet 1934;1:1117. Sindberg SE. Fracture of a sesamoid of thumb. J Bone Joint Surg 1940;22B:445-5. Clark P. Braunstein EM, Weissman BN, Sosman JL.
Salvage for failed implant arthroplasty of the wrist We have had to revise 19 wrist arthroplasties-seven total wrist arthroplasties.
silicone implants and 12 metal-on-plastic
Each of the seven silicone implants
was successfully
revised in one
operation; the four fusions and three total wrist implants were functioning 6 or more years after surgery.
Nineteen
operations
were needed to revise the total wrist implants.
because of loosening, six had become unbalanced, prostheses eventually
Four had failed
and two had become infected. All of the loose
required fusion. Four of the unbalanced
wrists were rebalanced,
but two
of these patients have pain; the other two cases required fusion. One infected wrist required fusion, and one is stable with an implant.
(J HAND SURG 1992;17A:917-23.)
Donald C. Ferlic, MD, Denver, Cob., Mack L. Clayton, MD, Denver, Colo.
From the University of Colorado Health Sciences Center, Denver, Colo., the Denver Orthopedic Clinic, Denver, Colo., and Littleton Orthopaedic Associates, Littleton, Colo. Received for publication Nov. 5, 1991; accepted in revised form March 17. 1992.
Susan N. Jolly, MD, Littleton,
Cola., and
One or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Donald C. Ferlic, MD, Denver Orthopedic Clinic, 2005 Franklin St., Fifth Floor. Denver, CO 80205. 311138436
917
