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Cuboid Fracture CUBOID FRACTURE Introduction The cuboid bone lies on the lateral side of the foot, in front of the calcaneus, and behind the fourth and fifth metatarsal bones. Isolated fractures of the cuboid are uncommon, and can be difficult to diagnose. They are more commonly part of more complex injuries, including the Lisfranc fracture- dislocation of the mid-foot. CT scan is often required to confirm the diagnosis and is usually required to fully assess the extent and nature of the injury, even when found on plain radiographs. Inadequately treated fractures of the body of the cuboid can lead to chronic disability. Anatomy The cuboid bone, showing its relations within the foot, (Gray's Anatomy, 1918). The cuboid forms an important structural element of lateral column of the foot. The peroneus longus tendon courses along the plantar surface of the cuboid bone in a lateral to medial direction. See also Appendix 1 below Mechanism Mechanisms of cuboid injury include: ● Minor fragmental avulsion fractures at ligament and capsule insertions are the most common form of cuboid injury. ● Direct trauma: ♥ Isolated fractures of the body are uncommon and are usually the result of direct trauma ● Indirect trauma: ♥ One particular injury pattern has been termed the “nutcracker fracture”.2 This results from an indirect compression force where the cuboid is crushed between the calcaneum and 4th and 5th metatarsals by axial torsional forces applied to the plantar-flexed foot ● More commonly cuboid fractures are seen in conjunction with other more complex injuries of the foot, such as the Lisfranc fracture-dislocation of the forefoot. ● Stress fractures may be seen occasionally as sports injuries ♥ This type of injury can occur as a result of normal stresses on abnormal bone, or as a result of abnormal stresses on normal bone. ● Occasionally they can take the form of (depending exactly on how one defines these injuries) a “Toddler’s fracture”. Classification Cuboid fractures can be classified in broad terms as: 1 1. Avulsion fractures. 2. Body fractures: ● Simple ● Stress ● Comminuted ● Crush. Complications Complications include: ● Compartment syndrome is an important acute complication of midfoot fractures in general. ● Chronic: ♥ Instability with loss of the normal architecture of the lateral arch. ♥ Chronic dysfunction of the peroneus longus, when the peroneal sulcus is damaged. ♥ Post-traumatic secondary arthritis Clinical Features Injuries to the cuboid may be subtle and can be misdiagnosed as lateral ankle sprains. Pain is a constant feature at the lateral margin of the foot. There may be point tenderness over the region of the cuboid (in distinction to the lateral malleolus in ankle injuries). This must provide for an index of suspicion for the injury, even if plain radiology is normal. Swelling and bruising may be present, but may not be depending on the exact nature and extent of the injury. Weight bearing may be difficult or impossible. Investigations Plain radiography Plain radiography may make the diagnosis, however the fracture may be very difficult to detect, and so if clinical suspicion is high, CT scan or MRI are further imaging options Routine views include A-P and lateral views of the foot. Additional medial oblique views of the foot may be required to see these fractures. The Os Peroneum, should not be confused with a fracture of the cuboid. The os peroneum is an small oval accessory ossicle located within the substance of the distal peroneal longus tendon as it courses near the cuboid bone. It may be confused for a fracture, but the margins are smooth, rounded and have sclerotic margins. Fractures of the os itself are possible. CT scan This is done to detect occult fractures of the cuboid bone, when plain radiographs are inconclusive. CT may also be done to more fully define the extent of a cuboid injury, often not apparent on plain radiography and to assess for possible occult fractures to adjacent bones. MRI Scan This is useful for the detection of occult fracture, not seen on plain radiography. It has the advantage over CT scan of better definition of associated soft tissue structures, such the ligaments, joint capsules and nearby tendons of the peroneus muscles Bone scan This is sensitive for occult fractures, not apparent on plain radiography, but is not as specific as CT scan or MRI. Management Diagnosis and treatment of subtle cuboid fractures is important to minimize long term disability. Minor cortical avulsion fractures can be allowed to weight bear immediately in a walking boot, or a back slab and crutches if there are significant symptoms for 2-3 weeks Simple non-displaced body fractures can generally be treated with a below knee plaster cast for 6 to 8 weeks or longer until there are radiographic signs of a bony union. More complex injuries than this will usually require operative management such as ORIF. The exact type of surgery required is based on a variety of factors including the degree of articular incongruity, the presence of subluxation or dislocation, loss of lateral column length, and associated foot fractures. Severely comminuted fractures may require arthrodesis. Disposition Most cuboid fractures, unless very minor avulsion injuries, should be referred to Orthopaedics, as even relatively minor disruptions of the cuboid can result in significant long term arthritis and disability. Appendix 1 Anatomy of the Cuboid bone: The left cuboid, Antero-medial view, (Gray's Anatomy, 1918) The left cuboid, Postero-lateral view, (Gray's Anatomy, 1918) Appendix 2 Radiology of the foot: Appendix 3 The Columns of the Foot The longitudinal arches (or columns) of the foot; Medial: ● 1st metatarsal, Medial cuneiform, Navicular, Talus Middle: ● 2nd and 3rd Metatarsals, Middle and Lateral Cuneiforms, Navicular, Talus Lateral: ● 4th and 5th Metatarsals, Cuboid, Calcaneum References 1. Miller R.S, Handzel C; J Isolated Cuboid Fracture: A Rare Occurrence; Am Podiatr Med Assoc 91(2): 85-88, 2001. 2. Hermel M.B, Gershon-Cohen J; The nutcracker fracture of the cuboid body by indirect violence. Radiology 60: 850, 1953. 3. Borelli J, et al. Fracture of the Cuboid; J Am Acad Orthop Surg 2012;20: 472-477. Dr J. Hayes August 2012 .
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