Cuboid Fractures

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Cuboid Fractures

• By Philip Parr

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Ligaments attaching to the Cuboid

• Superior
• The calcaneocuboid band of the bifurcate ligament
• dorsal calcaneocuboid ligament
• Inferior
• The superficial fibers of the long plantar
  ligament
• help to form the peroneal canal
• deep fibers of the long plantar ligament
• attach to the peroneal ridge
• short plantar 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

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Fractures of the Cuboid

• Avulsion
• Body
• Simple
• Stress
• Comminuted/Crush
• Fractures with dislocation

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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
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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
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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
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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
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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
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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
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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
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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 60850, 1953.
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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
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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
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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.
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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.
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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.
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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.
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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.
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FAI Study

• Operative technique (contd)
• 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.
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FAI Study

• Operative technique (contd)
• 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.
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FAI Study

• Operative Technique (contd)
• 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.
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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.
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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
  1-2 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.
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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.
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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.
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The End