Professional Documents
Culture Documents
Sesamoids &
Anatomical Variants
Daniel P. Evans, D.P.M.,
FACFAOM, FACPR
Professor, Dept. Podiatric
Medicine and Radiology
Scholl College of
Podiatric
Medicine
Sesamoid bones:
constant first MPJ
variable IPJ hallux
Accessory Bones
Os Trigonum
Lateral tubercle posterior process of the
talus
Separate point of ossification (usually fuses
by 18 yoa)
May have fibrous, cartilaginous or osseous
union with talus.
Occurrence 2-8%
Accessory Bones
Os Trigonum
Fused lateral tubercle known as
STEIDAS PROCESS or TRIGONAL
PROCESS
Fracture of the lateral tubercle known
as SHEPHERDS FRACTURE
Accessory Bones
Os Trigonum
Accessory Bones
Os Trigonum
Accessory Bones
Os Trigonum (Pediatric)
Accessory Bones
Os Trigonum (Steidas Process)
May cause marked
limitation of motion.
DJD
Impingement Os
Trigonum syndrome
Os Trigonum Syndrome
Accessory Bones
Os Trigonum (Shepherds fracture)
Accessory Bones
Os Tibiale Externum AKA Accessory
Navicular
Secondary center of ossification of
navicular tuberosity.
or
Accessory ossicle within the tendon of
posterior tibial tendon.
Occurrence 3 12%
Accessory Bones
Os Tibiale Externum: 2 Types
Pre-hallux pyramidal or D shaped.
May appear as a continuation of tuberosity of
navicular.
Cartilage or fibrocartilage attachment.
Accessory Navicular
Type I: Sesamoid in the tendon
Os Tibiale Externum
Os Tibiale Externum
Type I Accessory Navicular
Round or oval.
Separate from
navicular
tuberosity.
Intra-tendonous.
Accessory Bones
Os Tibiale Externum Type I
Depending on tube angulation ossicle
may appear in close proximity to the
tuberosity.
Pre-hallux OTE II
Accessory Bones
Pre-hallux OTE II (Medial Oblique)
Accessory Bones
Os Intermetatarseum
Located between the first cuneiform and
first and second metatarsal bases.
Generally located more dorsally
May be fused to one or all three bones
Accessory Bones
Os Intermetatarseum
Found on the anterior dorsolateral edge
of the first cuneiform
Can also be seen in fourth
intermetatarsal space
Occurrence 1-10%
Accessory Bones
Os Intermetatarseum
Accessory Bones
Os Intermetatarseum
Accessory Bones
Os Intermetatarseum (medial oblique)
Accessory Bones
Os Intermetatarseum.
Could represent an
incomplete duplication
of a metatarsal
polymetatarsia (appear
to have an extra digit,
commonly bil.) or
osteochondroma
(generally unilateral).
Surgical consideration
Accessory Bones
Os Supranaviculare (Os pirie, os unci)
Located dorsal aspect of T-N joint
Can be confused with
fracture/osteophyte
Occurrence 1%
Os Supranaviculare
Accessory Bones
Os Supranaviculare
Accessory Bones
Os Calcaneus Secundarius AKA Os
Calcaneum Sucundum
Located at the anterior surface of the
calcaneus (anterior process)
R/O anterior process fracture (Rowe 1C)
Often confused, missed at ER
Occurrence 1%
Accessory Bones
Os Calcaneus Secundarius
Os Calcaneus Secundum
Accessory Bones
Os Sustentaculi
Located posterior to the sustentaculum tali
Implicated in TC bar or bridge
Usually fused to sustentaculum tali
Best seen on Axial calcaneal projection
Rare <1%
Accessory Bones
Os Sustentaculi
Accessory Bones
Os Supratalare
Dorsum of talar head
Can resemble fracture (bone will have
jagged appearance in a fracture
whereas the accessory bone will not).
Accessory Bones
Os Supratalare
Os Supratalare or Old
Avulsion Fx.?
Accessory Bones
Os Vesalinum
Proximal tip of styloid process fifth metabase
Unfused secondary ossification center
Frequently confused with traction apophysis
Rare 1/10th of 1%
Accessory Bones
Os Vesalinum
Unfused secondary
apophysis of the 5th
metatarsal base?
Accessory Bones
Os Vesalinum
Accessory Bones
Apophysis
Os Vesalius?
Would the 5th
metatarsal base be
normal if this
ossicle was not
there?
Accessory Bones
Jones Fracture
Os Vesalius?
Os Vesalianum
or
Os Peroneum?
Accessory Bones
Accessory Ossicle of Hallux
IPJ ossicle medial or lateral aspect of of
joint near base of distal phalanx
Frequently mistaken for old fracture
Accessory Bones
Accessory Ossicle of Hallux
Accessory Bones
Os Subtibiale and Os Subfibulare
Distal medial and lateral malleoli
May represent a secondary ossification
center of medial or lateral malleolus
Rule out possible trauma via avulsion
fracture
Occurrence 4%
Accessory Bones
Os Subtibiale
Accessory Bones
Os Subtibiale (Pediatric)
Accessory Bones
Os Subfibulare
Os Sub Fibulare?
Sesamoids
Sesamoid Pattern
Sesamoids
Interphalangeal Sesamoid of Hallux
Located plantar head of proximal
phalanx of hallux between condyles.
Located either centrally or eccentric.
May remain cartilaginous and therefore
difficult to identify radiographically.
Occurrence 50%
Sesamoids
Interphalangeal
Sesamoid of Hallux
Central location
Located in the
plantar capsule
and attachment to
the flexor tendon.
Os Interphlangeus
Visualized on D-P,
Lateral raised Hallux
projection.
Eccentric
presentation
separate ossification
center from base or
possible fracture of
base of prox.
phalanx.
Sesamoids
Sesamoids of the Lesser MPJs
accessory sesamoids.
Second (1), fourth (1) and fifth (2)
metaheads
Joint capsules and short flexors
Sesamoids
Sesamoids of
Lesser MPJs
Circular or oval.
May be single or
multiple.
Rare Bi-Partite or
multipartite.
Sesamoids
Os Peroneum
Found in tendon of peroneus longus near
peroneal sulcus of cuboid.
Marked variation in size.
Presentation may appear altered due to
foot positioning, tube angulation.
Present in nearly everyone ossified 20%
Sesamoids
Os Peroneum
May assist in the
angular change of
course of peroneus
longus.
Calcification may
occur surrounding
the sesamoid.
Sesamoids
Multipartite Os Peroneum
ANATOMIC SESAMOIDS
Sesamoids
Sesamoids of First Metatarsal
Constant sesamoid nearly always
present
Within joint capsule and FHB
Articulates with plantar surface of first
MH
Purpose
Sesamoids appear where tendons
change their direction, and in these
zones they protect the tendon and give
it mechanical support. The hallucial
sesamoids, besides protecting the
tendon of the flexor hallucis longus,
give mechanical support to the
intrinsic musculature partially inserted
in them, so that the vector of plantar
force is greater on the hallux, helping
to stabilize the hallux on the ground
during the push-off phase
Sesamoids
Sesamoids of the First Metatarsal
Tibial sesamoid larger
Up to one-third are segmented usually
tibial
Ossifies by 10-12 yoa
Anatomical Variations
Bi-Partite Sesamoid
Tri-Partite Sesamoid
Variations in anatomical presentation
Sesamoids
Bipartite Sesamoids
Sesamoids
Bi-partite Tibial Sesamoid
Bi-partite Sesamoid
Sesamoids
Bipartite and Multipartite
Sesamoids
Patterns of Ossification
Bi-partite Tibial
Sesamoid
Multi-partite Fibular
Sesamoid
SESAMOID PATHOLOGY
PLAIN FILM
Dorsal Plantar
Lateral
Lateral Oblique
Medial Oblique (45
Axial Sesamoid
DORSAL-PLANTAR
Dorsal-Plantar Marked
Lesion
Place marker on
desired pathology.
Foot slightly plantar
flexed.
Shoot at 0 degrees
LATERAL
LATERAL OBLIQUE
40 degrees.
Fibular
Ses.
MEDIAL OBLIQUE
25 degrees
Tibial Ses.
AXIAL SESAMOID
90 degrees
Film placement
CR Plantar
3rd MT head
Patient position
Non-Weightbearing
Projections
Holly Projection
Causton Projection
Lewis Projection
HOLLY PROJECTION
Causton Sesamoid
Projection
Lewis Projection
Erosion of Crista
Negative Images
Bipartite Sesamoid
Two separate
components.
Components generally
not equal in size.
Edges are rounded.
Cortical density
completely surrounds
each ossification
center.
Tibial sesamoid is
more commonly
bipartite than
fibular sesamoid.
Tibial Sesamoid
(underdeveloped or
hypoplastic) and
non-ossified Fibular
sesamoid.
Fractured Sesamoid
Irregular line of
cleavage.
Lack of
continuous
cortical rim.
Mal-alignment
of edges.
Fracture
Fractured Sesamoid
Imaging of Painful Conditions of th Hallucial sesamoid Complex and Plantar Capsular Structures of the First Metatarophalangeal Joint:
Sanders T, Rathur S. Radiol Clin N Am 46 (2008) 1079-1092
Nonunion of Sesamoid Fx
Imaging of Painful Conditions of th Hallucial sesamoid Complex and Plantar Capsular Structures of the First Metatarophalangeal
Joint:
Tibial Sesamoid
AVN
Renandiers
Disease
Fibular Sesamoid
AVN
Trevors Disease
Vascular Supply to
Sesamoids
Vascular Supply to
Sesamoids
Imaging of Painful Conditions of th Hallucial sesamoid Complex and Plantar Capsular Structures of the First
Metatarophalangeal Joint:
Sanders T, Rathur S. Radiol Clin N Am 46 (2008) 1079-1092
Imaging of Painful Conditions of th Hallucial sesamoid Complex and Plantar Capsular Structures of the First Metatarophalangeal
Joint:
Late AVN
Imaging of Painful Conditions of th Hallucial sesamoid Complex and Plantar Capsular Structures of the First Metatarophalangeal Joint:
Sanders T, Rathur S. Radiol Clin N Am 46 (2008) 1079-1092
DJD
DJD
Cystic
Changes
Proximal Migration
of Sesamoids.
Imaging of Painful Conditions of th Hallucial sesamoid Complex and Plantar Capsular Structures of the First Metatarophalangeal Joint:
Sanders T, Rathur S. Radiol Clin N Am 46 (2008) 1079-1092
Imaging of Painful Conditions of th Hallucial sesamoid Complex and Plantar Capsular Structures of the First Metatarophalangeal Joint:
Sanders T, Rathur S. Radiol Clin N Am 46 (2008) 1079-1092
Imaging of Painful Conditions of th Hallucial sesamoid Complex and Plantar Capsular Structures of the First Metatarophalangeal Joint:
Sanders T, Rathur S. Radiol Clin N Am 46 (2008) 1079-1092
Screw Placement
Ultrasound
Only Dynamic Imaging Modality
Evaluate Motion, Impingement
Evaluate Screw Interference
Ultrasound
Radiographic Variants
Must know normal anatomy in
order to distinguish the
abnormal.
Is a finding truly pathological
or just simply normal anatomy
or a variant?
Radiographic Variants
Structural
Overlap
Radiographic Variants
Structural Overlap
Radiographic Variants
Soft Tissue Calcification (Monckberg)
Radiographic Variants
Benign Cortical Defect
Radiographic Variants
Radiographic Variants
Nutrient Foramen (Calcaneus)
Radiographic Variants
Angulation of the Epiphyseal Plate
Radiographic Variants
Offset of Distal Fibular Epiphysis
Radiographic Variants
Closure of the Epiphyseal Plate
Radiographic Variants
Epiphyseal Scar
Radiographic Variants
Radiographic Variants
Fibular Ossicle
Radiographic Variants
Talar Beaking
Radiographic Variants
Simulated Fracture from Trabeculae
Radiographic Variants
Simulated Cyst in Calcaneus
Radiographic Variants
Pediatric Calcaneal Apophysis
Radiographic Variants
Compact Bony Island
Radiographic Variants
Simulated Navicular Fracture
(Pediatric)
Radiographic Variants
Silver Dollar Navicular
Radiographic Variants
Silver Dollar Navicular
Radiographic Variants
Silver Dollar Navicular
Radiographic Variants
Normal Growth Fluctuations
(Navicular)
Radiographic Variants
Normal Growth Fluctuations
(Navicular)
Radiographic Variants
Simulated Lis Franc Dislocation
Radiographic Variants
Bipartite First Cuneiform
Radiographic Variants
Accessory Ossification Center
(Pseudo-epiphysis)
Radiographic Variants
Pseudo-epiphysis
Radiographic Variants
Pseudo-epiphyses
Radiographic Variants
Bifid & Pseudo-epiphyses
Radiographic Variants
Fifth Metatarsal Base Apophysis
Radiographic Variants
Metatarsal Base Clefts
Radiographic Variants
Simulated Cyst from Gun Barrel Effect
Radiographic Variants
Bifid (Cleft) Epiphysis
Radiographic Variants
Bifid Ossification Center (Hallux)
Radiographic Variants
Distal Phalangeal Condyles
Radiographic Variants
Fusion of the Middle and Distal
Phalanges
Radiographic Variants
Pointed Distal Phalanges
Radiographic Variants
Cone-shaped Epiphyses
Radiographic Variants
Cone-shaped Epiphyses
CONCLUSION
Regular review of anatomy is a must.
Most accessory structures are innocuous
and incidental findings, however they may
be associated with various pathologies.
Consider multiple views to assess.
If in doubt evaluating a unilateral x-ray,
view the contralateral side.
Sesamoids are subject to same disorders
affecting joints.
QUESTIONS?
Daniel P. Evans, D.P.M.,
FACFAOM, FACPR
Scholl College of
Podiatric
Medicine