Isolated Injury of the Cuboid Bone

Emergency Radiology (2002) 9: 272–277 DOI 10.1007/s10140-002-0240-9

ORIGINAL ARTICLE

Theodore T. Miller Æ Helene Pavlov Æ Monali Gupta Elizabeth Schultz Æ Craig Greben Isolated injury of the cuboid bone

Received: 25 June 2002 / Accepted: 18 July 2002 / Published online: 12 October 2002 Ó ASER 2002

Abstract The purpose of this study was to describe isolated injury of the cuboid bone as a potentially ra- Introduction diographically occult cause of foot pain. The imaging The cuboid is the keystone of the lateral arch of the foot, studies of 17 patients, 13 women and 4 men aged 17–79 articulating proximally with the hindfoot at the cal- years (average 45 years), who presented with pain over caneocuboid joint, medially with the lateral cuneiform, the lateral aspect of the midfoot were retrospectively and distally with the forefoot at the fourth and fifth reviewed. Frontal, lateral, and inversion-oblique radio- tarsometatarsal joints. It is thus subjected to stress graphs were available for all patients. In addition, MR across a wide range of foot motion but is not subjected imaging was performed in eight patients, CT in two, to direct weight-bearing forces [1]. conventional tomography in two, and bone scan in one. The cuboid is vulnerable to various types of injuries, Conventional radiographs revealed cuboid fracture in including dislocation [2, 3], direct crush injury resulting seven patients. Of the remaining ten, eight underwent from motor vehicle accidents or a heavy object falling on MR imaging which demonstrated four fractures, three the dorsum or lateral aspect of the foot [4], avulsion bone bruises, and one stress reaction, and two had to- injury involving any of its ligamentous attachments, e.g., mography, CT, and/or bone scan, all of which docu- the calcaneocuboid ligament [5], and fatigue-type stress mented an isolated cuboid fracture. Isolated fracture of fracture in both toddlers [6, 7] and adults [1, 8, 9]. the cuboid may be radiographically occult. Other The term ‘‘nutcracker fracture,’’ coined by Hermel imaging modalities, particularly MR imaging, can doc- and Gershon-Cohen [5] in 1953, describes compression ument this injury as the source of pain. of the cuboid between the calcaneus proximally and the Keywords Fracture Æ Cuboid Æ Foot Æ MR fourth and fifth metatarsals distally. The mechanism of imaging Æ Injury injury of their five patients with six injured feet was plantar flexion of the hindfoot and midfoot against the fixed forefoot. All six cuboid compression fractures were visible radiographically, and were associated with navicular fractures in five cases and subtalar dislocations in two; in only one case was the cuboid fracture isolated. In 1990 Sangeorzan and Swiontkowski [10] described four Presented at the annual meeting of the American Roentgen Ray cases of isolated displaced fractures of the cuboid, all Society, Washington, DC, May 2000 visible radiographically, and cited forced abduction of T.T. Miller (&) Æ M. Gupta Æ E. Schultz Æ C. Greben the forefoot as the compressive mechanism of injury. Department of Radiology, North Shore University Hospital, The purpose of this report is to describe 17 cases of 300 Community Drive, Manhasset, NY, USA isolated cuboid injury as a potentially diagnostically E-mail: [email protected] Tel.: +1-516-4658686 subtle cause of acute lateral foot pain, since in most of Fax: +1-516-4658620 these cases the injury was not evident on conventional radiographs at the time of initial clinical presentation. T.T. Miller North Shore Imaging Associates, P.C., 825 Northern Blvd., Great Neck, NY 11021, USA H. Pavlov Materials and methods Department of Radiology and Imaging, Hospital for Special Surgery, The imaging examinations of 17 patients from the two institutions 535 E. 70 St., New York, NY, USA of the authors, 13 women and 4 men, with an average age of 45 273 years (range 17–79 years), were retrospectively reviewed. All pa- demonstrated, while the bone scan displayed increased tients had originally been referred for evaluation of pain along the radiotracer uptake isolated to the cuboid. lateral side of their midfoot. The history and specific mechanisms of injury of eight of the Five of the 17 fractures were stress-related, only one patients are as follows: three of the patients reported acute onset of of which was evident radiographically as linear sclerosis. pain after inversion injury; two reported acute onset of pain after Of the other four, three underwent MR imaging, which ‘‘twisting’’ the foot, but could not remember or distinguish between demonstrated a discrete fracture line in the 17-year-old the mechanisms of flexion and inversion; a 17-year-old runner complained of gradual onset of pain over a 3-week period; a 74- runner and the 60-year-old women with seizure disorder year-old man who had recently taken-up golf complained of (Fig. 3), and generalized marrow edema in the 74-year- gradual onset of pain; and a 60-year-old woman on long-term old golfer. The fourth radiographically occult stress phenytoin therapy for chronic seizure disorder reported sudden fracture was visualized as linear sclerosis on CT and onset of severe pain as she stood up while getting out of bed one conventional tomography, and as linear uptake on bone morning. The history and mechanism of injury for the remaining nine patients is unknown. scan. Standard frontal, lateral, and inversion-oblique radiographs Of the three bone bruises on MR imaging, two oc- were performed in all patients. In addition, MR imaging was per- curred in the proximal aspect of the cuboid, near the formed in eight patients, CT in two, conventional tomography in calcaneocuboid joint, and the third occurred distally, two, and bone scan in one (Table 1). MR imaging consisted of combinations of T1-weighted and T2-weighted spin-echo se- near the tarsometatarsal joint. quences, with or without fat suppression, obtained in the axial, Follow-up MR imaging in two patients demonstrated sagittal, and coronal planes. The CT scans were performed with resolution of the fracture line in one and almost com- 3-mm-thick sections, and conventional tomography was performed plete resolution of the bone bruise in the other, both at 2-mm intervals, aligned with the cuboid. corresponding to resolution of symptoms. Another pa- Of the ten cases with advanced imaging, the time interval from injury to advanced imaging was 17 days (range 1 day to 6 tient with a fracture, 17 months after injury, still com- weeks). plains of lateral foot discomfort but has not returned for follow-up imaging. It is not possible to accurately determine the time to resolution of symptoms or to eval- Results uate outcome in the rest of our cases, as patients were lost to follow-up, follow-up office visits were spaced The results are summarized in Table 1. Only seven of the months apart, information regarding symptoms was not 17 cases were visible radiographically; three of these given for each office visit, or cases from the teaching files were comminuted ‘‘nutcracker’’-type compression frac- lacked pertinent information. tures, two were avulsions, one a vertical shear, and one a stress fracture. Of the remaining ten cases with normal radiographic Discussion findings, eight underwent MR imaging which demonstrated four cases of discrete fractures (Fig. 1), three General causes of pain after trauma to the foot are cases of focal marrow edema consistent with bone bruise fracture, dislocation, or injury to the ligaments and (Fig. 2), and one case of generalized marrow edema (in tendons. Fracture of the cuboid is usually associated the 74-year-old golfer), interpreted as a stress reaction. with fracture of the navicular bone [5, 11, 12] or is part In those patients who had conventional tomography of a fracture-dislocation pattern involving either the and/or CT examination a discrete fracture line was Chopart [4] or Lisfranc joints [13, 14]. Isolated fracture

Table 1 Imaging results of 17 patients with isolated injury of the cuboid bone Age (years), sex Radiographs MRI CT Tomography Bone scan Fracture type

18, M Positive Vertical shear 17, F Positive Avulsion 63, F Positive Avulsion 41, F Positive Comminuted–compression 67, F Positive Comminuted–compression 28, M Positive Comminuted–compression 35, F Positive Fatigue stress 29, F Negative Positive Positive Positive Fatigue stress 17, F Negative Positive Fatigue stress 74, M Negative Positive Fatigue stress 60, F Negative Positive Insuﬀ. stress 66, F Negative Positive Compression 35, M Negative Positive Positive Compression 58, F Negative Positive Vertical 53, F Negative Positive Bone bruise 79, F Negative Positive Bone bruise 29, F Negative Positive Bone bruise 274

Fig. 1a–c Radiographically occult fracture of the cuboid in a 58- year-old woman who suffered an inversion injury stepping into a Fig. 2a–c Radiographically occult injury of the cuboid in a 55- pot-hole. a Lateral radiograph 6 weeks after injury is normal. b year-old woman who suffered an inversion injury when an elevator Sagittal T1-weighted image (TR/TE 400/10) and c corresponding door closed on her foot. a Lateral radiograph 1 month after injury sagittal fat-suppressed fast spin-echo T2-weighted image (TR/eff. is normal. b Sagittal T1-weighted image (TR/TE 450/15) and c TE 4300/56; 8 echo train) 1 day after plain radiography corresponding sagittal fat-suppressed fast spin-echo T2-weighted demonstrate a fracture line (arrow) image (TR/eff. TE 3500/45; 8 echo train) 1 day after radiography demonstrate a focal area of abnormal signal intensity within the proximal aspect of the cuboid, interpreted as a bone bruise (arrows). Follow-up MR examination 17 months later showed almost complete resolution (images not shown) 275

Fig. 3a–c Radiographically occult insufficiency fracture in a 60- demonstrated 39 tarsal fractures and 9 bone bruises (2 of year-old woman on long-term antiseizure medication. a Antero- the bone bruises were actually fractures on CT). The posterior radiograph 1 week after injury shows osteopenia. A fracture is not evident. b Axial T1-weighted image (TR/TE 500/15) authors of that study do not mention whether any of the and c corresponding axial fat-suppressed fast spin-echo T2- cuboid fractures were isolated injuries, nor whether any weighted image (TR/eff. TE 4000/102; 12 echo train) 1 day after were radiographically occult. Despite the fact that MR the radiograph show the fracture line (arrow) imaging showed the same 41 sites of tarsal injury as CT plus an additional 7 sites of tarsal injury, the authors of the cuboid is rare [10, 15], and as demonstrated by our concluded that CT should be the initial imaging mo- series may be radiographically occult. dality, reserving MR imaging for evaluation of Lisfranc Bony causes of lateral pain, other than a cuboid ligament injury if bony injury is absent on CT. We dis- fracture, are fractures of the proximal shaft of the fifth agree with their conclusion, since a bone bruise that is metatarsal, avulsion of the base of the fifth metatarsal, not visible on CT but is demonstrable on MR imaging fracture of the fifth metatarsal distal to the tuberosity may explain the patient’s symptoms. [16], and chip fracture or avulsion of the anterior process Ultrasonography [25] and scintigraphy [1, 7, 24] have of the calcaneus [17, 18]. Injuries to an os peroneum may also been advocated for the evaluation of the painful also be responsible for pain as a result of an acute post-traumatic foot. Wang et al. [25] detected fractures fracture, chronic fracture with stenosing tenosynovitis of of the foot and ankle sonographically in 24 patients, the peroneus longus tendon, or partial tearing of the including two cuboid fractures in a study of 268 patients peroneus longus tendon [19]. Lateral soft tissue injuries, with post-traumatic foot pain and normal radiographs. such as of the lateral ligament complex and peroneal However, limitations of ultrasonography for assessment tendons, may also be a source of pain, and, as in eight of of bone injury are the inability to visualize a bone bruise, our cases, MR imaging may be requested to evaluate inability to visualize the cortical disruption of a fracture clinically suspected soft tissue injury in the setting of on the deep surface of bone or a surface not accessible to normal radiographs. the insonating beam, and the inability to distinguish While MR imaging is generally regarded as the mo- small cortical irregularities from fracture. Bone scintig- dality of choice for evaluating radiographically occult raphy is a widely available and familiar modality, but fractures [20, 21, 22, 23], CT [8, 13], scintigraphy [1, 7, the exact site of uptake may be difficult to determine in 24], and ultrasonography [25] have also been advocated an anatomically complex region such as the midfoot, for the evaluation of fracture in the painful post-trau- and the extent, course, and type of fracture may not be matic foot. Preidler et al. [13] examined 49 patients discernible. with hyperflexion injuries using radiography, CT, and The three cases of bone bruise of the cuboid in our MR imaging. Radiographs revealed only 20 tarsal series may represent the forme fruste of a nutcracker- fractures, whereas CT demonstrated 41 tarsal fractures, type mechanism of injury which produced trabecular 11 of which occurred in the cuboid, and MR imaging microfracture instead of gross cortical and trabecular 276 fracture. Two of these cases occurred proximally in the MR imaging is the preferred method for the evaluation cuboid, at the calcaneocuboid articulation, and the third of suspected radiographically occult fractures. occurred in the distal aspect of the cuboid, at the In summary, isolated injury of the cuboid may occur tarsometatarsal joint, suggesting such a compressive and may be radiographically occult. Other imaging mechanism. Similarly, bone bruise in the cuboid is il- modalities, particularly MR imaging, may be necessary lustrated by Robbins et al. [18] in a case of calcaneoc- to demonstrate these injuries as the cause of pain. uboid joint compression with a ‘‘kissing’’ contusion in the body of the cuboid and a fracture of the anterior process of the calcaneus. References In addition to the typical compressive and avulsive types of cuboid injury, our series contained five stress 1. Beaman DN, Roeser WM, Holmes JR, Saltzman CL (1993) fractures. 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