1

C OPYRIGHT Ó 2019 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Fracture of the Sesamoid Bone of the Thumb

A Case Report and Review of the Literature
Mira van der Naald, MD*, Niels van der Naald, MD*, Detlef van der Velde, MD, and Arnold H. Schuurman, MD, PhD

Investigation performed at the University Medical Center Utrecht, Utrecht, and St. Antonius Hospital, Nieuwegein, the Netherlands

Abstract
Case: Fracture of a sesamoid bone of the thumb is rare. We report a case of such a fracture after hyperextension of the
thumb in a 26-year-old woman. After a volar plate injury was excluded, she was treated nonoperatively with 5 weeks of
immobilization followed by physical therapy.
Conclusion: After reviewing the current literature describing sesamoid fractures of the thumb, we recommend that
fracture of the sesamoid of the metacarpophalangeal (MCP) joint should be regarded as an avulsion fracture. The role of
surgical intervention should be limited to patients with a painful nonunion.

A
sesamoid bone is an ossification in a tendon or ligament
over a joint that decreases friction and protects the
tendon. In the metacarpophalangeal (MCP) joint of
the thumb, sesamoid bones are embedded in the volar plate.
The flexor pollicis brevis muscle inserts on the radial sesamoid,
and the adductor pollicis muscle inserts on the ulnar sesa-
moid1. Although the prevalence of sesamoid bones in the hand
varies greatly, 99.5% to 100% of people have 2 sesamoid bones
on the volar side of the MCP joint of the thumb2,3. The sesa-
moid bones of other MCP joints are more varied in prevalence,
ranging from 0.9% to 61.8%3. The presence of a sesamoid bone
of the interphalangeal (IP) joint of the thumb is 13.1% to
100%2-4. A fracture of these bones rarely is diagnosed. We
report the case of a fractured sesamoid bone of the thumb
after a hyperextension trauma. We performed a systematic
literature review of sesamoid fractures of the thumb, and we
suggest a treatment option for these injuries.
The patient was informed that data concerning the case
would be submitted for publication, and she provided consent.
Case Report
the ulnar collateral ligament, and the radial collateral ligament.
The flexion and extension tendons were intact, although maxi-
mum extension was limited by pain. Anterior pressure on the
proximal phalanx did not result in subluxation in the MCP joint.
Radiographs showed an isolated complete fracture of the ulnar
sesamoid bone of the MCP joint of the thumb (Figs. 1 and 2).
The thumb was immobilized with a plaster cast with the
MCP joint in 30° of flexion for 5 weeks, but the wrist and the IP
joint remained free. After 5 weeks, the function of the MCP joint
was limited, with an active flexion of 22°. After 1 month of
physical therapy, the active flexion had improved to 39°. A radi-
ograph demonstrated normal union of the fracture with good
callus formation (Fig. 3). At the 1-year follow-up, the patient had
regained full function, although the range of motion was limited
to 35° in active flexion. She reported sporadic minor discomfort.
Review of the Current Literature
T he literature on isolated fractures of the sesamoid bone of
the thumb is limited (Table I). The first publication that
describes this type of injury dates from 19155. In our search of
the literature, we identified 40 previously published cases4,6-23.

W hile attending a festival, a 26-year-old woman sustained

an injury when another guest was being pushed and fell
against the patient’s dominant right hand. The thumb was
hyperextended, and there was immediate pain and swelling at
the thenar eminence with a vasovagal response. Two days later,
the patient presented to our emergency department with an
edematous first MCP joint and tenderness of the volar plate,
The patients ranged in age from 16 to 75 years old, with an
average age of 35 years. In the cases that specified that the
sesamoid bone was affected, 73% (24 of 33) involved an iso-
lated fracture of the ulnar sesamoid bone, while 24% (8 of 33)
of the cases involved a fracture of only the radial sesamoid bone
and 1 of the cases described a fracture of both sesamoids. The
type of trauma was described in 27 cases, of which 26% (7 of

*M. van der Naald, MD, and N. van der Naald, MD, contributed equally to this paper.

Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest
forms are provided with the online version of the article (http://links.lww.com/JBJSCC/A770).

JBJS Case Connect 2019;9:e10 d http://dx.doi.org/10.2106/JBJS.CC.18.00147

 2
J BJ S C A S E C O N N E C T O R FRACTURE OF THE SESAMOID BONE OF THE THUMB
V O LU M E 9 N U M B E R 1 F E B R UA R Y 13, 2 019
d d

Fig. 1 Fig. 2
Fig. 1 Lateral radiograph of the right thumb demonstrating an isolated sesamoid fracture of the first MCP joint. Fig. 2 Anteroposterior radiograph of the
right thumb showing no other lesions.

27) reported a fall; 50% (10 of 20) of the fractures occurred

during sports. Immobilization was reported as a treatment in
80% (32 of 40) of the cases. The length of immobilization
varied from 5 days to 4 weeks. A short period of immobiliza-
tion was the most common treatment. In 78% (25 of 32) of
these cases, the immobilization was for £4 weeks, and in 63%
(20 of 32), the immobilization period was £3 weeks. Only
1 case explicitly described no immobilization. Primary opera-
tive treatment has not been reported. Only 2 older publications
suggested excision of the sesamoid bone for painful nonunion17,22.
In reports specifying the outcome, 91% (31 of 34) of patients fully
recovered. Of these cases, 50% (17 of 34) of patients described a
full recovery within 8 weeks. Other reports did not specify the
time of follow-up. One patient reported persistent pain, and 2
patients were unable to fully flex the thumb at the last follow-up.
All of the other publications did not report outcomes.

Conclusion

F racture of the sesamoid bone of the thumb is uncommon.

In our search of the literature, there was a trend for a short
period of immobilization with good clinical results (as with
our patient). We suggest a short period of immobilization of
£3 weeks and early physical therapy, if needed, for the treat-
ment of a sesamoid bone fracture of the first MCP joint with an Fig. 3
intact volar plate. To our knowledge, there has been no evi- Lateral radiograph of the right thumb showing callus formation at 2 months
dence reported regarding the difference of treatment between a after the initial trauma.

J BJ S C A S E C O N N E C T O R
V O LU M E 9 N U M B E R 1 F E B R UA R Y 13, 2 019
d d
TABLE I Overview of the Current Literature on Fractures of the Sesamoid Bones of the First MCP Joint*
Article Specification of Injury
12
Deabate et al. (2011) Fracture of the radial sesa-
moid bone
11
Connolly et al. (2008) Fracture of the ulnar sesa-
moid bone
16
Fotiadis et al. (2007) Fracture of the ulnar sesa-
moid bone
15
Fogerty et al. (2007) Fractures of the radial and
ulnar sesamoid bones
21
Shaw et al. (2003) Comminuted fracture of the
ulnar sesamoid bone
7
Altun et al. (2000) Fracture of the ulnar sesa-
moid bone
6
Altun et al. (1998) Fracture of the ulnar sesa-
moid bone
13
Dodenhoff (1996) Displaced fracture of the
MCP sesamoid
14
Dong et al. (1995) 7 cases with an isolated
ulnar sesamoid fracture,
1 case associated with an
MCP joint dislocation
(excluded)
van der Lei et al. 3 cases of fracture of the
23
(1995) ulnar sesamoid bone of the
thumb
18
Ishizuki et al. (1994) 7 cases: 2 fractures of the
ulnar sesamoid and 5 frac-
tures of the radial sesamoid
10
Brüser (1994) 3 fractures of the ulnar
sesamoid bone
9
Bianchi et al. (1993) 4 cases: 2 fractures of the
ulnar sesamoid bone and 2
fractures of the radial sesa-
moid bone
19
Patel et al. (1990) 2 closed fractures and
1 open fracture of the thumb
sesamoid associated with
laceration of the palmar
plate in a child (excluded)
3
FRACTURE
Case Description
44-year-old man: hyperex-
tension trauma during a
gymnastic exercise
19-year-old man: related
to a football match
35-year-old man: violent
abduction injury during a
football game
39-year-old man: heavy
object fell on hand
26-year-old man: fell
against a pool table
16-year-old girl: handball hit
on the thumb
25-year-old man: fell on
outstretched hand while
working in a mine
75-year-old woman: fell onto
outstretched palm
5 fractures were sport-
related; 2 fractures were
related to falls
Case 1: 35-year old man fell
on outstretched hand during
football; Case 2: 32-year-old
man stumbled from the
stairs and fell on out-
stretched hand; and Case
3: 33-year-old woman fell on
outstretched hand while
playing handball
2 fractures from a direct
blow; 5 fractures due to
hyperextension
Not available
Not available
Not available
OF THE SESAMOID BONE
Treatment
Splint for 3 wk
Cast for 3 wk, followed by
intermittent active mobiliza-
tion for an additional 3 wk
Immobilization with elastic
bandages and anti-inflamma-
tory drugs for 5 days
Immobilized for 2 wk, exercise
Thumb spica cast and analge-
sia; after 14 days, encouraged
to mobilize the thumb
Splint for 3 wk
Splint for 3 wk
Thumb placed in a spica cast,
but this did not relieve pain
adequately; therefore, a
scaphoid-type cast was placed
5 fractures treated with splint
or cast (2-3 wk) and 2 frac-
tures were taped
Case 1: cast for 2 wk followed
by active retraining exercises;
Case 2: cast for 10 days fol-
lowed by active retraining
exercises; Case 3: cast for 2
wk followed by active retrain-
ing exercises
6 cases with 4 wk of immobi-
lization and 1 case with no
immobilization (no other
treatment specified)
Not available
Nonoperatively with
immobilization
Splint for 2-3 wk
OF THE THUMB
Result
Resumed full work at 6 wk
after the injury
Full recovery: regained a full
painless range of move-
ment of the thumb
Full recovery of function
after 6 wk
Full function after 2 wk
After 6 wk, pain-free and
normal function
After 8 wk, no pain and able
to resume handball
No pain and returned to
work 6 wk later
At 6 wk, pain-free but unable
to actively flex the thumb
fully
7 fractures had pain-free
normal function after 6-8 wk
Case 1: after 3 wk, virtually
full range of motion; how-
ever, for 5 mo, considerable
pain. After 1 year, pain
completely resolved; Case
2: after 8 wk, complete
relief from pain with almost
full range of motion; Case 3:
after 5 wk, regained full
range of motion, and after 8
wk had complete relief from
pain
No residual symptoms in 5
cases (no timing of follow-
up included); 1 case with
persistent pain (had not
received immobilization)
and 1 case with persistent
weakness of the thumb (last
follow-up at 6 mo)
Not available
Normal hand function was
restored in all 4 patients
Normal hand function was
restored in both patients
with closed fractures
continued
 4
J BJ S C A S E C O N N E C T O R FRACTURE OF THE SESAMOID BONE OF THE THUMB
V O LU M E 9 N U M B E R 1 F E B R UA R Y 13, 2 019
d d

TABLE I (continued)

Article Specification of Injury Case Description Treatment Result

Hansen and Peterson 2 cases of sesamoid frac- Not available If pain persists after immobili- Not available
17
(1987) ture of the thumb zation, excision of the bone is
curative
8
Bell et al. (1985) Fracture of the ulnar sesa- 16-year-old boy: hyperex- Removable splint for 8 wk with After 4 wk, still tender with
moid bone and tear in the tension injury in an attempt mobilization exercises of the discomfort; after 8 wk, pain-
volar plate to catch an American joint free with full range of motion
football
22
Wood (1984) 2 cases of sesamoid Not available The treatment of disabling Not available
fracture pain in a sesamoid bone is
enucleation of the bone
20
Scobie (1941) Crushed ulnar sesamoid 62-year-old man: while Bandage around a ball of Complete recovery resulted
bone holding the steering wheel cotton-wool in a few days
of the car in his right hand
(the thumb being upper-
most and pointed forward
and to the left), he collided
with a stationary car. The
force of impact was trans-
ferred through the steering
column and the wheel to the
base of the thumb

*MCP = metacarpophalangeal.

simple avulsion fraction and a comminuted fracture. Mecha- Detlef van der Velde, MD3
nisms described by authors are mostly fall or sports-related, Arnold H. Schuurman, MD, PhD1
suggesting hyperextension trauma. Only 1 group noted a direct 1Department of Plastic, Reconstructive and Hand Surgery, University
trauma, but those authors also defined the trauma mecha- Medical Center Utrecht, Utrecht, the Netherlands
nism as hyperextension15. Because of the anatomy and the
trauma mechanism, we conclude that a fracture of the ses- 2Trauma Unit, Department of Surgery, University Medical Center Utrecht,
amoid of the MCP joint should be regarded as an avulsion Utrecht, the Netherlands
fracture. It is our expert opinion that surgery should only be
3Trauma
considered for painful nonunion. n Unit, St. Antonius Hospital, Nieuwegein, the Netherlands

E-mail address for N. van der Naald: n.vandernaald@umcutrecht.nl

ORCID iD for M. van der Naald: 0000-0002-4949-625X

ORCID iD for N. van der Naald: 0000-0002-7380-462X
Mira van der Naald, MD1 ORCID iD for D. van der Velde: 0000-0003-2653-5989
Niels van der Naald, MD2 ORCID iD for A.H. Schuurman: 0000-0002-0483-3048

References
1. Yammine K. The prevalence of the sesamoid bones of the hand: a systematic
review and meta-analysis. Clin Anat. 2014 Nov;27(8):1291-303. Epub 2014
Feb 25.
2. Amar E, Rozenblat Y, Chechik O. Sesamoid and accessory bones of the hand—an
epidemiologic survey in a Mediterranean population. Clin Anat. 2011 Mar;24(2):
183-7. Epub 2010 Oct 29.
3. Chen W, Cheng J, Sun R, Zhang Z, Zhu Y, Ipaktchi K, Zhang Y. Prevalence and
variation of sesamoid bones in the hand: a multi-center radiographic study. Int J Clin
Exp Med. 2015 Jul 15;8(7):11721-6.
4. Msamati BC, Igbigbi PS. Radiographic appearance of sesamoid bones in the
hands and feet of Malawian subjects. Clin Anat. 2001 Jul;14(4):248-53.
5. Skillern PG On fractures of the sesamoid bones of the thumb Ann Surg. 1915
Sep;62(3):297-301.
6. Altun M, Erdil H, Sahin H, Gumusburun E. Fracture of the ulnar sesamoid of
the metacarpophalangeal joint of the thumb: a case report. Clin Anat. 1998;
11(1):60-1.
7. Altun M, Erdil H, Aras H, Gumusburun E. Fracture of the ulnar sesamoid of the
thumb in a handball player. Clin J Sport Med. 2000 Oct;10(4):300-1.
8. Bell MJ, McMurtry RY, Rubenstein J. Fracture of the ulnar sesamoid of the met-
acarpophalangeal joint of the thumb—an arthrographic study. J Hand Surg Br. 1985
Oct;10(3):379-81.
9. Bianchi S, Abdelwahab IF, Zwass A, Molini L. Fractures of the sesamoid bone of
the thumb. Bull Hosp Jt Dis. 1993 Summer;53(3):7-10.
10. Brüser P. [Pathology of the sesamoid bones of the hand]. Handchir Mikrochir
Plast Chir. 1994 Nov;26(6):302-6. German.
11. Connolly CM, Alsousou J, Hassan S, Williams NW. Don’t avoid the sesamoids:
fracture to the ulnar sesamoid of the first metacarpophalangeal joint. Emerg Med J.
2008 Mar;25(3):184.
12. Deabate L, Garavaglia G, Lucchina S, Fusetti C. Fracture of the radial sesamoid
bone of the thumb: an unusual fracture. Chin J Traumatol. 2011;14(5):309-11.
13. Dodenhoff RM. Fracture of the thumb sesamoid: a new physical sign. Injury.
1996 Apr;27(3):213-4.
 5
J BJ S C A S E C O N N E C T O R FRACTURE OF THE SESAMOID BONE OF THE THUMB
V O LU M E 9 N U M B E R 1 F E B R UA R Y 13, 2 019
d d

14. Dong PR, Seeger LL, Shapiro MS, Levere SM. Fractures of the sesamoid bones
of the thumb. Am J Sports Med. 1995 May-Jun;23(3):336-9.
15. Fogerty S, Pacheco R, McLaren CAN. Simultaneous fractures of the ulnar
and radial sesamoid bones of the thumb. J Hand Surg EurVol. 2007 Jun;32(3):
358-9.
16. Fotiadis E, Samoladas E, Akritopoulos P, Chatzisimeon A, Akritopoulou K. Ulnar
sesamoid’s fracture of the thumb: an unusual injury and review of the literature.
Hippokratia. 2007 Jul;11(3):154-6.
17. Hansen CA, Peterson TH. Fracture of the thumb sesamoid bones. J Hand Surg
Am. 1987 Mar;12(2):269-70.
18. Ishizuki M, Nakagawa T, Ito S. Hyperextension injuries of the MP joint of the
thumb. J Hand Surg Br. 1994 Jun;19(3):361-7.
19. Patel MR, Pearlman HS, Bassini L, Ravich S. Fractures of the sesamoid bones of
the thumb. J Hand Surg Am. 1990 Sep;15(5):776-81.
20. Scobie WH. Crush fracture of sesamoid bone of thumb. Br Med J. 1941 Dec 27;
2(4225):912.
21. Shaw M, Lyburn ID, Torreggiani WC, Watura R. Comminuted fracture of the ulnar
sesamoid of the metacarpophalangeal joint of the thumb: an uncommon injury. J
Emerg Med. 2003 May;24(4):437-9.
22. Wood VE. The sesamoid bones of the hand and their pathology. J Hand Surg Br.
1984 Oct;9(3):261-4.
23. van der Lei B, van der Linden E, Mooyaart EL, Klasen HJ. Fracture of the thumb
sesamoid bone: a report of three cases and a review of the English-language liter-
ature. J Trauma. 1995 May;38(5):836-40.