Cuboid Fractures
By: Philip Parr
Ligaments attaching to the Cuboid
-
Superior:
-
-
Inferior:
The superficial fibers of the long plantar ligament
-
-
-
attach to the peroneal ridge
short plantar ligament
-
-
help to form the peroneal canal
deep fibers of the long plantar ligament
-
-
The calcaneocuboid band of the bifurcate ligament
dorsal calcaneocuboid ligament
attach to the coronoid process
lateral calcaneocuboid ligament
interosseous ligaments (cuneocuboid and cuboideonavicular), dorsal ligaments
(dorsal cuneocuboid and dorsal cuboideonavicular), and plantar tarsometatarsal
ligaments (plantar cuboideonavicular and plantar cuneocuboid) that help to secure
the cuboid.
FHB: origin at cuboid, along with 3rd cun, PT tendon
Fractures of the Cuboid
• Avulsion
• Body
– Simple
– Stress
– Comminuted/Crush
– Fractures with dislocation
How Cuboid Fractures Occur
• Fractures to the cuboid body occur as an axial
rotatory force is applied to the plantarflexed
foot, which leads to a crescent-shaped
fracture at the TM joint.
• Can also occur as a result of direct trauma to
the area
Miller, R. Isolated Cuboid Fracture: A rare occurrence. J Am Podiatr Med Assoc
91(2): 85-88, 2001
Stress Fractures of the Cuboid
• These are very rare, and only a few cases have
been reported in the literature
• Result of abnormal stress on normal bone
• Can be due to the abnormal gait of a toddler or
secondary to increased instability at the MT joint.
• Instability creates increased pronation, causing
the peroneus longus muscle to pull against a less
stable fulcrum.
• May mimic peroneal tendonitis, C-C jt arthritis,
Cuboid subluxation.
Miller, R. Isolated Cuboid Fracture: A rare occurrence. J Am Podiatr Med Assoc
91(2): 85-88, 2001
Crush Fractures of the Cuboid
• Occur when the cuboid is compressed between
the base of the 4th/5th metatarsals, and the
calcaneus as a result of a severe abduction of the
forefoot.
• The term “nutcracker effect” was coined by
Hermel and Gerson-Cohen in 1953.
• Crush fractures can also occur as a result of
severe trauma to the dorsal or lateral aspect of
the foot, which is unlikely to affect the cuboid
alone.
Miller, R. Isolated Cuboid Fracture: A rare occurrence. J Am Podiatr Med Assoc
91(2): 85-88, 2001
Cuboid Dislocation
• Due to anatomical factors, total dislocations
of the cuboid are rare.
- The most common direction is inferomedial, due
to the variable nature of the plantar ligaments and
the thickness of the dorsal and lateral capsular
and extracapsular ligaments.
Miller, R. Isolated Cuboid Fracture: A rare occurrence. J Am Podiatr Med Assoc
91(2): 85-88, 2001
Avulsion Fractures
• Most often occur as a result of tension of:
– Inferior Calcaneocuboid ligament
– Lateral band of the bifurcate ligament
– Tarsometatarsal ligaments
Miller, R. Isolated Cuboid Fracture: A rare occurrence. J Am Podiatr Med Assoc
91(2): 85-88, 2001
Diagnosis of Cuboid Fractures
• Plain Film
– Lateral
– DP
– MO: best plainfilm view
• Bone Scan
• CT
• MRI
Miller, R. Isolated Cuboid Fracture: A rare occurrence. J Am Podiatr Med Assoc
91(2): 85-88, 2001
Treatment
• Simple body fractures and non-displaced
avulsion fractures:
– BK Weightbearing Cast for 6-8 wks
Miller, R. Isolated Cuboid Fracture: A rare occurrence. J Am Podiatr Med Assoc
91(2): 85-88, 2001
Conservative vs Surgical Treatment of
Displaced Fractures
• Review of the literature:
– Main and Jowett 1975 study reported poor results
w/ conservative treatment  recommended ORIF
– DeLee advocated immediate treatment with ORIF
to decrease the chance of DJD.
– Hermel and Gerson-Cohen believed immediate
fusion was the best way to treat an intraartcular
fracture
MAIN BJ, JOWETT RL: Injuries of the midtarsal joint. J Bone Joint Surg Br 57: 89, 1975.
DELEE JC: “Fractures and Dislocations of the Foot,” in Surgery of the Foot, 5th Ed, ed by RA Mann, p 592, CV Mosby, St Louis,
1986.
HERMEL MB, GERSHON-COHEN J: The nutcracker fracture of the cuboid body by indirect violence. Radiology 60:850,
1953.
Conservative vs Surgical Treatment of
Displaced Fractures
• In cases of displaced fractures, the first
line of treatment should be closed
reduction using an inversion-adduction
force, while simultaneously pushing the
cuboid superiorly.
• If this fails, treatment by ORIF is
advised.
Miller, R. Isolated Cuboid Fracture: A rare occurrence. J Am Podiatr Med Assoc
91(2): 85-88, 2001
Complications
•
•
•
•
Malunion
DJD
Persistant subluxation
Pes planovalgus
Miller, R. Isolated Cuboid Fracture: A rare occurrence. J Am Podiatr Med Assoc
91(2): 85-88, 2001
FAI Study
• 12 Patients with a displaced fracture of the
cuboid.
– 7 men, 5 women age 19-68.
– 4 patients with polytrauma
– 10 of 12 had combo of cuboid fracture with
another midfoot injury, 2 with isolated cuboid fx.
– 5 required immediate fasciotomy for impending
compartment syndrome.
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
FAI Study
• Two basic fracture patterns:
– 1) Fractures involving an impaction of the
dorsolateral aspect of the articular facets to
metatarsals 4 and 5 (11 of 12 pts).
– 2) Additional crush fracture of the body of the
cuboid, with consecutive shortening of the lateral
column of the foot (5 of 12 pts).
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
FAI Study
•
•
•
•
•
8 of 12 were from MVA
1 from fall from horse
1 crush
1 paraglide
1 “sprain”
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
FAI Study
• Average delay to cuboid reconstruction in 9
patients was 12 days.
• One patient operated on immediately due to
an irreducible complete medial midfoot
dislocation.
• 2 patients operated on 6 and 7 weeks after
the trauma.
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
FAI Study
• Operative technique
– Lateral incision along the axis of the fibula the the
intermetatarsal space 4-5.
– The branches of sural nerve protected and
Peroneus Tertius tendon partly released.
– PB and PL tendons retracted plantarly and the
lateral central portion of EDB muscle is elevated.
– Ex-fix applied with pins in anterior process of calc,
and the prox 4th met, used as distractor.
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
FAI Study
• Operative technique (cont’d)
– The periosteum over the fracture of the lateral wall is
incised vertically, or in a T-type fashion, depending on
fracture configuration.
– Lateral wall opened, and the fracture and joints
inspected.
– In the crush-type fractures, the depressed fragments
elevated and the joint surface reconstructed.
– In 7 of 12 patients, blocks from the iliac crest were
needed for bony support.
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
FAI Study
• Operative technique (cont’d)
– The lateral wall fragments were then reduced, and
the construct stabilized using 2 2.0 mm plates
dorsolaterally and plantarlaterally.
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
FAI Study
• Operative Technique (cont’d)
– Intraop oblique radiograph obtained, and quality
of articular reconstruction and reestablishment of
lateral column length is judged compared to preop
oblique radiograph of opposite side.
– Construct tested for stability by releasing
distractor.
– If not stable enough, ex-fix can be left for 4 weeks.
– Peroneus tertius tendon is then repaired and
wound closed in layers.
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
FAI Study
• Postop treatment: NWB in cast x 6 wks, PWB
boot for 4-6 wks. Unprotected full WB
allowed at 12 wks.
• F/U: Overall f/u was 12-47 mos, ave 27.
– At latest f/u, radiographs taken of both feet to
assess lateral column and cublid length.
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
FAI Study
• Results
– No intra- or postop complications, wound healing
uneventful.
– WB progressed as planned. No correction was
lost secondarily.
– Lateral column length restored, but a step off of 12 mm between articular facets to the 4th and 5th
met present in 2 patients.
– No secondary operations have been necessary,
with the exception of hardware removal.
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
FAI Study
• Results:
– Residual disability was seen in nine out of the 12
patients.
– Three of them complained of pain in the lateral
column, three of pain in the medial column and
two of diffuse stiffness in the midfoot.
– Discomfort seemed to be worse for the patients
with medial column pain than for patients with
lateral column pain. The worst result was seen in
the patient with the crush injury of the foot.
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
FAI Study
• Conclusions
– CT Scan is necessity
– Iliac Crest Corticocancellous bone grafts
– ORIF needed for displaced cuboid fractures mostly
to restore lateral column length.
– No non-operative control group
Weber, M and Locher, S. Reconstruction of the Cuboid in Compression Fracture: Short to
Midterm results in 12 patients. FAI 2002.
The End