cuboid fractures by: philip parr. ligaments attaching to the cuboid -superior: -the calcaneocuboid...

Cuboid Fractures

By: Philip Parr

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

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.


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.


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.


Avulsion Fractures

• Most often occur as a result of tension of:– Inferior Calcaneocuboid ligament– Lateral band of the bifurcate ligament– Tarsometatarsal ligaments


Diagnosis of Cuboid Fractures

• Plain Film– Lateral– DP– MO: best plainfilm view

• Bone Scan• CT• MRI


Treatment

• Simple body fractures and non-displaced avulsion fractures:– BK Weightbearing Cast for 6-8 wks


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

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.

MAIN BJ, JOWETT RL: Injuries of the midtarsal joint. J Bone Joint Surg Br 57: 89, 1975.

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


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).


FAI Study

• 8 of 12 were from MVA• 1 from fall from horse• 1 crush• 1 paraglide• 1 “sprain”


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.


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.


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.


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.


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.


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.


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


The End

cuboid fractures by: philip parr. ligaments attaching to the cuboid -superior: -the calcaneocuboid...

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