Working Diagnosis:
Combined radial and ulnar sesamoid fracture of the right hand.

Treatment:
We agreed with the literature and proceeded to treat the patient by casting the right hand in a thumb spica Exos cast Case Photo #3 , with the thumb molded in 30 degrees of flexion. We left the patient in the cast for a total of 3 weeks and then removed it and reevaluated the patient to prevent stiffening.

Outcome:
Following the three weeks of casting, an additional set of x-rays were ordered for the patient which displayed a stable alignment of the previously seen non-displaced fractured ulnar sesamoid bone of the thumb. Also, a slight indistinctness of the lucent fracture line was seen, suggestive of early bone remodeling. On clinical exam, he had persistent yet improved tenderness to palpation of both sesamoids and improved end range of thumb adduction and grip strength, with other range of motion of the thumb being intact. With these findings, the patient was progressing well and we felt it necessary to continue with our current treatment plan of range of motion exercises and return to play precautions. The patient was able to make a full recovery and was very satisfied with his care.

Author's Comments:
This case was a very interesting and insightful case for a variety of reasons. First off, the incidence of sesamoid fractures is quite rare, and even more rare to have a combined ulnar and radial sesamoid fracture. In this, it is important to understand how to manage a unique fracture such as this, as well as to keep it in the differential with patients with traumatic thumb injuries. This is not only apparent and applied to patients in handball, but also can be applied to soccer, basketball, and stick and bar sports such as hockey, lacrosse, and gymnastics. Importantly, when presented with a combined sesamoid fracture as this, it is first important to distinguish between conservative and operative management. To make this decision, it is necessary to determine if thumb flexion and abduction is full and intact. If so, conservative management with thumb placed in 30 degrees of flexion for 3 weeks is warranted, and quite possibly 5 weeks if necessary, though 3 weeks is preferred to prevent stiffening. If the thumb flexion and abduction is not intact, it may be necessary to proceed to operative management.

References:
1. "Fractures of the sesamoid bone of the thumb." Bianchi, S., Abdelwahab, IF., Zwass, A., Molini, L. Bull Hosp Jt Dis. 1993 Summer; 53(3):7-10.
2. "Simultaneous fractures of the ulnar and radial sesamoid bones of the thumb." Fogerty, S., Pacheco, R., McLaren, CA. Journal Hand Surgery Euro Vol. 2007 June; 32(3):358-9.
3. Exos cast picture: "New Cast for Broken Bones". ABC 7 Chicago Online, Newswire, Ivanhoe. February 4, 2013. http://abc7chicago.com/archive/8979971/
4. Handball Picture: "Thierry Omeyer of France Rules Handball's Hardest Position." WN news. January 19, 2015.https://article.wn.com/view/2015/01/19/Thierry_Omeyer_of_France_Rules_Handball_s_Hardest_Position/

Other x-ray images obtained on patient in case.

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