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Sesamoid Bone: Interesting Case
265 Plays9 days ago
Hand Therapy Academy welcomes Allison to the show, where she and Miranda dive into a unique and intriguing case involving the sesamoid bone. From unexpected challenges to surprising insights, this conversation sheds light on a rarely discussed topic in hand therapy.
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Transcript
Introduction to Ham Therapy Academy
00:00:07
Miranda Materi
Hello, I'm Miranda.
00:00:08
Allison Johnson
And I'm Allison and we are Ham Therapy Academy.
00:00:12
Miranda Materi
All right, today we have Allison on and she is going to share an interesting case. And I'll let her present her case the way she presented to me because it was very interesting. And you're like, hmm, I wonder what's going on. And I think when she tells you what's going on, you might be surprised.
Case Presentation: Unusual Tendon Injury
00:00:30
Allison Johnson
So and this started with a patient who I was treating for a zone two EPL laceration that was repaired. um he came to us a little late, but not maybe at like three weeks or so after surgery. And we took him through the extensor tendon protocol.
00:00:45
Allison Johnson
It was going pretty well. Great thumb IP extension. he was doing well. But when it came down to it, he was a little further out. His IP joint was a very stiff into flexion.
00:00:57
Allison Johnson
His strength was doing great. No lag, extensor lag, anything like that. It was just that dang stiffness of the thumb IP joint into flexion. That was his main goal. He wanted his thumb tipped to bend more. So he was coming in, we were mobilizing the joint, we were stretching it passively.
Challenges in Treatment and Stagnation
00:01:15
Allison Johnson
He had a static progressive thumb IP flexion splint he was using religiously at home to try to get him more motion. so we did this for a couple months, worked on trying to get that IP flexion back.
00:01:29
Allison Johnson
And it initially it was improving, but very slowly. Like every progress note, we would maybe get five degrees of flexion in the IP joint.
00:01:40
Allison Johnson
So we get to a progress note and it had maybe improved like one degree. We were really reaching that plateau. And he had been still following up with his surgeon. So I kind of told him, I'm like, we're kind of reaching a
Unexpected X-Ray Findings
00:01:51
Allison Johnson
plateau. He had the end feel was pretty hard in that joint. So i suggested he go back to his surgeon and maybe have an x-ray, see if anything was going in that joint. Maybe it was arthritic, something like that.
00:02:04
Allison Johnson
So he goes back to his surgeon and lo and behold, the reason we couldn't get more thumb flexion is because his sesamoid bone had become lodged into his IP joint and was in the way. So I'm like, no wonder it on the volar side.
00:02:15
Miranda Materi
um the on the on the whole side, right?
00:02:19
Allison Johnson
yeah Yes. And his injury was on the dorsal side. It was an extensor tendon injury. So was really, it was weird. Even his surgeon texted me and was like, there was a sesamoid bone lodged in his IP joint. Like this is so weird, especially for an injury that wasn't even on that side of the thumb.
Surgical Intervention and Recovery
00:02:33
Miranda Materi
That's very weird.
00:02:34
Allison Johnson
So
00:02:34
Miranda Materi
what is What type of it? Like, what was the mechanism of injury?
00:02:38
Allison Johnson
he cut it with a, uh, like a box cutter or a knife when he was trying to open a box.
00:02:43
Miranda Materi
Oh, yeah.
00:02:43
Allison Johnson
That's how he, no, wasn't smashed or crushed or anything like that.
00:02:44
Miranda Materi
So not like a...
00:02:48
Allison Johnson
Um, so like a clean cut to the extensor tendon. Yeah. um, his surgeon did like a local anesthetic and removed the testemoid bone. Um, you what?
00:02:59
Miranda Materi
Gosh, I wonder how big was. yeah i like how i wonder how big the sesamoid bone was.
00:03:06
Allison Johnson
um You know, I'm not like super familiar with like sesamoid bone size, but it seemed pretty large. Like he took a picture of it. The surgeon took a picture of like the sesamoid bone that he removed.
00:03:12
Miranda Materi
Did it?
00:03:16
Allison Johnson
and And he took a picture of like how far he could bend the thumb IP joint when his, like after he removed it and it was significantly more.
Reflection: Was Surgery Needed Sooner?
00:03:25
Allison Johnson
So that was really cool. But yeah, I would have never in a million years thought the sesamoid bone would be lodged in the joint.
00:03:33
Allison Johnson
Have you ever like seen anything like that?
00:03:35
Miranda Materi
Never, never.
00:03:36
Allison Johnson
It wasn't even on my
00:03:37
Miranda Materi
And I wouldn't, you know, I would think, well, like I can see why they might not get an x-ray. Right. Right. But it, I guess it makes sense that an x-ray is such a simple test.
00:03:47
Allison Johnson
Yes.
00:03:48
Miranda Materi
And if you have joint but I would definitely think it'd be the EPL that was stuck in scar.
00:03:49
Allison Johnson
I know.
00:03:53
Allison Johnson
Totally. Yeah, exactly. um so it was just so interesting. And then, but it like, it made me think, so he just recently had that done, like maybe a week
Post-Surgery Rehabilitation
00:04:04
Allison Johnson
or two ago. So he's back in therapy. We're working on still getting more of that mobility.
00:04:09
Allison Johnson
Last time his incision was still open, but we'll start on scar management on that side. So more adhesions don't form, but so interesting. And it just makes me think like, I wish I would have like maybe sent him sooner, you know, to have an x-ray treatment.
00:04:23
Allison Johnson
because you know, there was a bone in the way yeah
00:04:26
Miranda Materi
Yeah, but you know, in some ways too, maybe. Yeah, they might have not. Like if earlier, they might be like, well, it's pretty normal to get have a stiff IP after an EPLS.
00:04:36
Allison Johnson
way.
00:04:36
Miranda Materi
I don't know.
00:04:38
Allison Johnson
I know that's so true too, but yeah, so no,
00:04:40
Miranda Materi
for me do like Did you feel like, did he have pain on the vular side at all?
00:04:44
Allison Johnson
no.
00:04:46
Miranda Materi
But in your mind, did you think this doesn't seem right?
00:04:50
Allison Johnson
Yeah, because it was like, so it was hard to end feel like it didn't, this like is weird, but didn't feel like it was his EPL stuck in adhesions and his scar, like on his dorsal thumb was really pliable, that kind of thing.
00:04:51
Miranda Materi
okay.
00:05:01
Allison Johnson
So it didn't ever feel like adhesions. That's why like I was like, maybe like the joint became like arthritic or something, but you know now looking
00:05:08
Miranda Materi
Mm-hmm. No, that's good to know though, right? I think that's good to share with share with everyone because we don't know.
00:05:13
Allison Johnson
Yeah, because we don't know. And I guess I kind of forget about sesame oil. And that's just
Surgeon's Perspective and Case Documentation
00:05:22
Allison Johnson
so.
00:05:22
Miranda Materi
we never really talk about them, right? They don't really have a lot of value in what we do or we're not really addressing them that often.
00:05:25
Allison Johnson
Yeah, they're not. you
00:05:30
Allison Johnson
Right. Yeah, but that kind of made me think like, do you have like, a timeframe of when like something like that occurs that you're like, let's go back and see if we can get more imaging or do you, do you do what I did and kind of go till we actually reach a plateau?
00:05:47
Miranda Materi
I mean, I probably would have done what you did, but I think the hardened feel would be, you know, like a flag to me, but also like, and I, and I know they typically follow up with their surgeon once a month.
00:05:58
Miranda Materi
Right. So I think even, yeah, of course, the sooner you address it, the better, but also, you know, a couple of weeks, I don't know, you know, significant difference that would have made.
00:06:06
Allison Johnson
Totally.
00:06:11
Miranda Materi
Or sometimes i've even heard surgeons say, especially with tendon injuries, we have to wait for the tissues to reach that tissue equilibrium, meaning they've gone through the inflammatory and the proliferative phase before we're going to even do any surgery.
00:06:19
Allison Johnson
totally
00:06:26
Miranda Materi
So I wonder if, you know, if it would have been earlier, if they would have even been waited to do surgery just to decrease the chances of having like an inflammatory response.
00:06:35
Allison Johnson
Oh yeah, that makes sense.
00:06:36
Miranda Materi
Oh, yeah.
00:06:37
Allison Johnson
Okay. Yeah, that's a good point. That makes me feel better. it was so funny when the patient,
00:06:40
Miranda Materi
but ah So how much emotion did he gain after the surgery?
00:06:45
Allison Johnson
um, when he came back into me, he was in a lot of pain, just post-op pain, but he still got 10, like immediately 10 more degrees than before he,
Sharing and Contact Information
00:06:54
Allison Johnson
before the surgery, before we had worked on it at all.
00:06:57
Allison Johnson
So that was good. So I expect him to continue progressing.
00:07:02
Miranda Materi
Interesting.
00:07:03
Allison Johnson
He's very excited. He's like, when he called me after he saw his doctor, and he's like, you're never going to guess. And I'm like, what? He's like, there's a bone. I'm like, what are you talking about? like, oh, a sesame bone.
00:07:14
Allison Johnson
That's crazy. Okay.
00:07:16
Miranda Materi
Yeah. And so as you were like talking about this earlier, before we got on, Alice and I were like just reviewing sesamoid bones and, and they can be in the joint capsule. So I suppose a little shift or maybe, you know, even, you know, holding it in a prolonged position, maybe that sesamoid just kind of floated into the joint space and it was super rare.
00:07:36
Allison Johnson
know
00:07:37
Miranda Materi
I wonder if there's any reports of it in the literature.
00:07:38
Allison Johnson
Yeah.
00:07:40
Allison Johnson
I know. I wonder. Cause so I was talking to his surgeon a little bit about it too. And he said he has seen something like that happen, but with a volar injury, you know what I mean?
00:07:51
Allison Johnson
Like there, it was an injury on that side of the, um, that would make sense.
00:07:52
Miranda Materi
Yeah. And I think that would make sense.
00:07:56
Allison Johnson
Right. But yeah, not for an extensor tendon laceration.
00:07:59
Miranda Materi
Yeah, it would be it would be an interesting case for him to write up.
00:08:03
Allison Johnson
Yeah, that's true.
00:08:05
Miranda Materi
Maybe the next capstone student.
00:08:07
Allison Johnson
ah Oh, yeah. Great idea.
00:08:09
Miranda Materi
ah
00:08:10
Allison Johnson
Yeah. So just wanted to talk about that.
00:08:12
Miranda Materi
Yeah.
00:08:13
Allison Johnson
And I wonder if there's any more stories out there like that.
00:08:17
Miranda Materi
Yeah. Well, thank you for sharing. And if anybody has any stories stories or anything to share or insights or patient cases, please reach out to us at Ham Therapy Academy or you can email us at info at Ham Therapy Academy.