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Cuboid Fracture
From WikiSM
Contents
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
Associated Conditions
- Lisfranc Injury
- Chopart Injury
- Navicular Fracture
- Cuneiform Fracture
- Hindfoot Fractures
- Midfoot Fractures
Pathoanatomy
- Cuboid
- Articulates with calcaneus (proximal), lateral cuneiform (medial), and metatarsals 4 and 5 (distal)
- Stabilizes calcaneocuboid joint, supports lateral column and functions as fulcrum during contraction of peroneus longus
Risk Factors
- Sports
- Ballet Dancers
Differential Diagnosis
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Plantar Fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
- Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
- Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
- Toenail
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)
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
- Place in a Short Walking Boot
- weight bearing as tolerated
- 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
Complications
- Pain
- Stiffness
- Instability
- Reduced length of lateral column
- Foot Osteoarthritis
- Coalition with other midfoot bones[17]
See Also
- Internal
- External
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
References
- ↑ Hermel MB, GERSHON-COHEN J. The nutcracker fracture of the cuboid by indirect violence. Radiology. 1953;60:850–854
- ↑ Court-Brown CM, Zinna S, Ekrol I. Classification and epidemiology of mid-foot fractures. Foot. 2006;16:138–41.
- ↑ Court-Brown C, Zinna S, Ekrol I. Classification and epidemiology of midfoot fractures. Foot. 2006;16:138–141.
- ↑ Yu G, Yu T, Yang Y, Yuan F. Old nutcracker fracture of cuboid. Indian J Orthop. 2013;47:310–2.
- ↑ 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.
- ↑ Chen JB. Cuboid stress fracture. A case report. J Am Podiatr Med Assoc. 1993;83:153–155.
- ↑ Yu SM, Dardani M, Yu JS. MRI of isolated cuboid stress fractures in adults. AJR Am J Roentgenol. 2013;201:1325–30
- ↑ Blumberg K, Patterson RJ. The toddler's cuboid fracture. Radiology. 1991;179:93–94
- ↑ Yu SM, Dardani M, Yu JS. MRI of isolated cuboid stress fractures in adults. AJR Am J Roentgenol. 2013;201:1325–1330.
- ↑ 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.
- ↑ Angoules, Antonios G., et al. "Update on diagnosis and management of cuboid fractures." World journal of orthopedics 10.2 (2019): 71.
- ↑ O'Dell MC, Chauvin NA, Jaramillo D, Biko DM. MR imaging features of cuboid fractures in children. Pediatr Radiol. 2018;48:680–685.
- ↑ 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.
- ↑ 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.
- ↑ Pountos, Ippokratis, Michalis Panteli, and Peter V. Giannoudis. "Cuboid injuries." Indian journal of orthopaedics 52.3 (2018): 297-303.
- ↑ 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.
- ↑ 17.0 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.
- ↑ 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.