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Cuboid Fracture

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Other Names

  • Cuboid fracture
  • Cuboid avulsion fracture
  • Nutcracker fracture
  • Cuboid stress fracture
  • Cuboid Single Fracture
  • Isolated cuboid fracture

Background

  • This page refers to fractures of the Cuboid
    • Including both traumatic and stress fractures
    • Cuboid subluxation, often called Cuboid Syndrome, is discussed separately

History

  • "Nutcracker" fracture first described by Hermel and Gershon-Cohen in 1953[1]

Epidemiology

  • Rare fracture pattern, poorly described in the literature
  • Midfoot are rare and have an annual incidence of approximately 3.6/100,000 fractures[2]
    • Cuboid makes up about 50% of of these
  • Annual frequency reaches 1.8 per 100000 in the United Kingdom[3]

Pathophysiology

  • General
    • Rare fracture pattern, some presentations limited to case reports
    • Rarely occur in isolation
  • Challenges
    • Diagnostically challenging, often missed in minor trauma[4]

Etiology

  • Fracture types
    • Isolated avulsion fractures are most common
    • Combined with other midfoot fractures
    • Combined with other midfoot dislocations
    • Associated with Lisfranc joint injuries
  • Nutcracker fracture/ Isolated fracture
    • Can occur as the result of indirect compression with axial force applied to a plantar-flexed, abducted foot
    • Crashing the cuboid between the calcaneal and the bases of the 4th and 5th metatarsals
    • Most commonly involve lateral aspect
    • Can disrupt mechanical alignment of the foot[5]
  • Avulsion fracture
    • Due to traumatic avulsion of calcaneocuboid ligament
    • Seen from ankle sprain with hindfoot everted, forefoot adducted
  • Stress fracture
    • Less common than other tarsal stress fractures as cuboid is not a weight-bearing bone[6]
    • Occur most often in young athletes[7]
    • Can also be seen in toddlers[8], adults[9] and military recruits[10]

Associated Conditions

Pathoanatomy

Risk Factors

  • Sports
    • Ballet Dancers

Differential Diagnosis

Clinical Features

Local tenderness to direct palpation of the cuboid bone following foot injury may suggest cuboid fracture.[11]
  • History
    • In acute injuries, there is usually a history of trauma
    • Patients will endorse dorsolateral foot pain
    • Antalgic gait, trouble weight bearing, especially on lateral side of foot
    • In patients with stress injuries, history is more consistent with an overuse injury
    • Pain may be mild and progressive
  • Physical Exam: Physical Exam Foot
    • Stress fractures may have no obvious clinical signs
    • Dorsolateral swelling, ecchymosis may be present
    • Tenderness to lateral midfoot at the cuboid
    • Stress fractures may have palpable mass if there is periosteal reaction or sclerosis
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • AP view: can evaluate medial and lateral columns
    • Lateral: assess congruency of the calcaneocuboid joint
    • Oblique: assess the integrity of the tarsometatarsal joints
  • Additional considerations
    • Imaging of contralateral limb if diagnostic uncertainty
    • Stress or weight bearing views to evaluate for stability/ instability

CT

  • May better detail the fracture, inter-osseous instability

MRI

  • General
    • Sensitive in both adults and children[12]
    • Imaging modality of choice in suspected stress fracture
  • Findings[13]
    • T1: continuous hypointense signals, fat suppression
    • T2: hyperintense signal in the bone, loss of the bone marrow signal is detected

Ultrasound

  • Role in evaluation of cuboid fracture not well defined
    • Wang et al: 24/268 patients with post traumatic foot pain and negative radiographs had fractures on US[14]

Classification

OTA Classification of Cuboid Fractures[15]

Orthopedic Trauma Association Classification

  • Cuboid fractures can be
    • Group A: extra-articular
    • Group B: the involving calcaneocuboid or metatarsocuboid joint
    • Group C: complex injuries involving both major joint surfaces
  • Subdivision
    • Further subdivided based on complexity, plane, and the part of the bone involved

Fenton Classification

  • Type 1[16]
    • Avulsion fracture involving the capsule of the calcaneocuboid joint
    • Most common type
  • Type 2
    • Stable, isolated extra-articular fractures
    • Length of the foot lateral column is maintained
  • Type 3
    • Isolated intra-articular fractures within the body of the cuboid
    • Involving the calcaneocuboid, the tarsometatarsal joint, or both of them
  • Type 4
    • Intra-articular fracture that require anatomic reduction and stabilization
    • Associated with disruption of the midfoot, tarsometatarsal injuries
  • Type 5
    • Crush injuries of the cuboid
    • May be accompanied by disruption of the mid-tarsal joint, loss of length of the lateral column alone

Management

  • Major factors determining management
    • Disruption of the articular surface
    • Loss of lateral column length

Nonoperative

  • Indications
    • Vast majority of cases
    • Nondisplaced fractures
    • Avulsion fractures
    • Stress Fracture
    • Fenton Type 1-3
  • Avulsion Fractures
  • Nondisplaced fractures
    • Immobilize in a Short Leg Cast
    • Non-weight bearing for 4-6 weeks
    • Gradually advance weight bearing at 2-4 weeks
  • Stress Fracture
    • For general management, see Stress Fracture (Main)
    • Must limit activity with a slow return to sport
    • Address any risk factors

Operative

  • Indications
    • Compressed
    • Intra-articular
    • Displaced or shortened > 1 mm
    • Open
    • Fenton Type 4, 5
  • Technique
    • Open reduction, internal fixation

Rehab and Return to Play

Rehabilitation

  • Postoperative
    • Week 1-6: Short Leg Cast, non weight bearing
    • Week 6: Place in walking boot, advance weight bearing status

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Postoperative
    • Most surgical outcomes and results based on case reports and small cases series
    • Weber et al: among 12 patients, no complications, residual articular step in 2 patients, early degenerative changes in 4[17]
    • Yu et al: fair results in 4 patients, good results in 2 patients[18]

Complications

  • Pain
  • Stiffness
  • Instability
  • Reduced length of lateral column
  • Foot Osteoarthritis
  • Coalition with other midfoot bones[17]

See Also

References

  1. ↑ Hermel MB, GERSHON-COHEN J. The nutcracker fracture of the cuboid by indirect violence. Radiology. 1953;60:850–854
  2. ↑ Court-Brown CM, Zinna S, Ekrol I. Classification and epidemiology of mid-foot fractures. Foot. 2006;16:138–41.
  3. ↑ Court-Brown C, Zinna S, Ekrol I. Classification and epidemiology of midfoot fractures. Foot. 2006;16:138–141.
  4. ↑ Yu G, Yu T, Yang Y, Yuan F. Old nutcracker fracture of cuboid. Indian J Orthop. 2013;47:310–2.
  5. ↑ Hunter JC, Sangeorzan BJ. A nutcracker fracture: Cuboid fracture with an associated avulsion fracture of the tarsal navicular. AJR Am J Roentgenol. 1996;166:888.
  6. ↑ Chen JB. Cuboid stress fracture. A case report. J Am Podiatr Med Assoc. 1993;83:153–155.
  7. ↑ Yu SM, Dardani M, Yu JS. MRI of isolated cuboid stress fractures in adults. AJR Am J Roentgenol. 2013;201:1325–30
  8. ↑ Blumberg K, Patterson RJ. The toddler's cuboid fracture. Radiology. 1991;179:93–94
  9. ↑ Yu SM, Dardani M, Yu JS. MRI of isolated cuboid stress fractures in adults. AJR Am J Roentgenol. 2013;201:1325–1330.
  10. ↑ Greaney RB, Gerber FH, Laughlin RL, Kmet JP, Metz CD, Kilcheski TS, Rao BR, Silverman ED. Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology. 1983;146:339–346.
  11. ↑ Angoules, Antonios G., et al. "Update on diagnosis and management of cuboid fractures." World journal of orthopedics 10.2 (2019): 71.
  12. ↑ O'Dell MC, Chauvin NA, Jaramillo D, Biko DM. MR imaging features of cuboid fractures in children. Pediatr Radiol. 2018;48:680–685.
  13. ↑ Hagino T, Ochiai S, Watanabe Y, Senga S, Takayama Y, Haro H. A case of a cuboid bone stress fracture in a senior high school rugby athlete. AP-SMART. 2014;1:132–135.
  14. ↑ Wang CL, Shieh JY, Wang TG, Hsieh FJ. Sonographic detection of occult fractures in the foot and ankle. J Clin Ultrasound. 1999;27:421–425.
  15. ↑ Pountos, Ippokratis, Michalis Panteli, and Peter V. Giannoudis. "Cuboid injuries." Indian journal of orthopaedics 52.3 (2018): 297-303.
  16. ↑ Fenton P, Al-Nammari S, Blundell C, Davies M. The patterns of injury and management of cuboid fractures: a retrospective case series. Bone Joint J. 2016;98-B:1003–1008.
  17. ↑ 17.0 17.1 Weber M, Locher S. Reconstruction of the cuboid in compression fractures: Short to midterm results in 12 patients. Foot Ankle Int. 2002;23:1008–13.
  18. ↑ Yu G, Yu T, Yang Y, Li B, Yuan F, Zhou J, et al. Nutcracker fracture of the cuboid: Management and results. Acta Orthop Belg. 2012;78:216–9.
Created by:
John Kiel on 5 October 2021 17:33:19
Authors:
Last edited:
4 October 2022 12:35:00
Categories:
Lower Extremity | Trauma | Foot | Fractures | Acute

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