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Accessory Ossicles,

Sesamoids &
Anatomical Variants
Daniel P. Evans, D.P.M.,
FACFAOM, FACPR
Professor, Dept. Podiatric
Medicine and Radiology
Scholl College of
Podiatric
Medicine

Accessory Bones and


Sesamoids
Both occur in addition to the regularly
occurring primary osseous structures of
the foot and ankle.
Accessory bones anomalous
development of ossification patterns
Sesamoid bones arise in tendons and
joint capsules

Accessory Bones and


Sesamoids
Accessory bones:
arise earlier
usually larger
irregular in shape

Sesamoid bones:
constant first MPJ
variable IPJ hallux

Accessory Bones and


Sesamoids
Ossicle and Sesamoid Pattern

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.

Os Tibiale Externum within tendon of


tibialis posterior (sesamoid).
Round or oval in shape.

Accessory Navicular
Type I: Sesamoid in the tendon
Os Tibiale Externum

Type II: Articulating accessory


ossification center of the navicular.
Pre-hallux

Type III: Fused secondary ossification


center.
Cornuate navicular, Gorilloid navicular.
(Elongation of tuberosity of navicular)
Christman: Foot and Ankle Radiology -pg. 174

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 Navicular Type III


Elongation of
tuberosity of
navicular.
Fusion of a prehallux or secondary
ossification center.
Cornuate or
Gorilloid navicular.

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

Rowe 1-C Fracture


Fracture of anterior
process of
calcaneus.

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

Normal Tibial and


Fibular Sesamoids.
Note Tibial
Sesamoid is larger.
Density of Tibial
Sesamoid is
greater Why?

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

Standard Plain Film


Advanced Plain Film
Computed Tomography
Magnetic Resonance Imaging
Ultrasound

PLAIN FILM

Dorsal Plantar
Lateral
Lateral Oblique
Medial Oblique (45
Axial Sesamoid

DORSAL-PLANTAR

Annals of Surgery v. 60 (4) Oct. 1914

Dorsal-Plantar Marked
Lesion
Place marker on
desired pathology.
Foot slightly plantar
flexed.
Shoot at 0 degrees

Marked Lesion D-P

LATERAL

LATERAL OBLIQUE
40 degrees.

15 Degree Lateral Oblique

Fibular
Ses.

MEDIAL OBLIQUE
25 degrees

45 Degree Medial Oblique

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

Valgus Rotation of Hallux

Lat Dev Sesamoid

Erosion of Crista
Negative Images

Bi-Partite vs. Fracture


Line of Cleavage
Separation of bipartite sesamoids in
cardinal body planes.
Combined segments of bipartite sesamoid
larger than uninvolved sesamoid.
Fracture indicates disruption of FHB and
may lead to destruction of fragments.
Fracture fragments lytic due to hyperemia.

Bipartite Sesamoid
Two separate
components.
Components generally
not equal in size.
Edges are rounded.
Cortical density
completely surrounds
each ossification
center.

Bi-partite Tibial Sesamoid

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 Tibial Sesamoid

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:

Fracture vs. AVN


Check for lines of lucency
Evaluate height of sesamoid on axial
sesamoid view.
Evaluate internal density of sesamoid
matrix.

Tibial Sesamoid
AVN
Renandiers
Disease

Fibular Sesamoid
AVN
Trevors Disease

Vascular Supply to
Sesamoids

Arterial Anatomy of the Hallucial Sesamoids.


Rath B, notermus H, et.al. Clinical Anatomy 22:755-760 (2009)

Vascular Supply to
Sesamoids

Arterial Anatomy of the Hallucial Sesamoids.


Rath B, notermus H, et.al. Clinical Anatomy 22:755-760 (2009)

AVN Tibial 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

AVN of Tibial Sesamoid

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

Pain sub first metatarsal


head

Cystic
Changes

Pt. with Bilat. Nucleated


Callus

Plantar Plate Rupture


Rupture of
intersesamoidal
ligament.

Proximal Migration
of Sesamoids.

Plantar Plate Rupture

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

Plantar Plate Rupture

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

Plantar Plate Rupture

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

Anatomic Sesamoid Analysis


Always start with Plain film analysis.
Consider alternate projections.
Axial Sesamoid Assists in providing great detail.
15 degree Lateral Oblique Projection for Lateral
Sesamoid.
45 degree Medial Oblique Projection for Medial
Sesamoid.

C.T for Cortical involvement


MRI for Marrow involvement
Ultrasound dynamic exam, screw implications.

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

Nutrient Foramen (Tibia)

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

Transverse Growth Lines

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