Proximal sesamoid: fracture

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Introduction

Diagnosis

Differential diagnosis

Diagnosis

Clinical signs

Apical fractures

  • Acute:
    • Moderate to severe lameness (3-5/5) within 24 h of race.
    • Weightbearing on toe to avoid tension on palmar fetlock.
    • Joint effusion (not if non-articular fracture or recent intra-articular steroids).
    • Pain on flexion (not marked, decreases with chronicity).
    • Pain on digital palpation of apex of sesamoid (not consistent).
  • Chronic: positive response to nerve joint blocks.

Midbody fractures

  • More soft tissue swelling than apical fractures.
  • Lameness can be severe. 

Abaxial fractures

  • Usually non-articular, although articular fractures occur less commonly - joint effusion if articular fracture.
  • Soft tissue swelling along palmar or plantar surface.
  • Lameness.

Basilar fractures

  • Usually articular.
  • Lameness.
  • Soft tissue swelling.
  • Pain on flexion.

Comminuted or biaxial fractures

  • Non-weightbearing lameness as often associated with suspensory apparatus breakdown.
  • Fetlock swelling - fragments of sesamoids often palpable palmarly/plantarly.
  • Joint effusion.
  • Crepitus on manipulation.
  • Hyperextended fetlock.

Sagittal fractures

  • Rare.
  • Horse may present for more obvious condylar fracture.

Outcomes

Prognosis

  • Depends on the size of the fragment and damage to the suspensory apparatus.
  • Good - for small apical and basilar fragments.
  • Poor - for larger fragments and midbody, sagittal, comminuted or biaxial fractures.

Reasons for treatment failure

  • Septic arthritis    .
  • Implant failure.
  • Contralateral limb complications.
  • Loss of vascular integrity to distal limb in breakdown injuries.
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