Type 3 Cuboid Fracture
8 yo F with trauma. Diagnosis? • Xray of the Week
Figure 1. Trauma in a 8 year old female. Diagnosis?
Figure 2. Cuboid Bone Fracture. Fracture indicated by orange arrow. (A) Dorsoplantar radiograph of the foot demonstrating an isolated fracture of the cuboid with possible extension into the tarsometatarsal joint. (B) Medial oblique radiograph of the foot demonstrating an isolated fracture of the cuboid.
Introduction:
Fracture of the cuboid or disturbance of its articular relationships can lead to profound disruption of the movement and biomechanics of the foot [1,2]. Significant foot dysfunction can result from cuboid injury since the cuboid bone acts as a crucial supporting structure within the lateral column of the midfoot, and the articulation between the cuboid and the fourth and fifth metatarsals makes the largest contribution to dorsiflexion and plantar flexion of the midfoot [1].
Epidemiology:
Cuboid fractures are uncommon, occurring in 5% of all tarsal fractures [3]. The most common pattern of cuboid injury involves avulsion types. These occur with inversion of the hindfoot and adduction of the forefoot combined with external rotation of the tibia resulting in avulsion of the calcaneocuboid portion of the bifurcate ligament [1,3].
Diagnosis:
The diagnosis of a cuboid fracture can be established when there is a high index of suspicion secondary to significant swelling of the midfoot region and a positive history of direct or indirect trauma to the foot accompanied by local tenderness [3]. Radiographic evidence can support the diagnosis. A standard three view foot series (lateral, dorsoplantar, and medial oblique) should be obtained to evaluate a midfoot fracture. A fracture of the cuboid is best appreciated on the medial oblique view because as the foot is rolled medially, the cuboid comes into full, unobstructed view, which allows visualization of the joints in question, swelling of the surrounding soft tissues, or avulsion [2]. More sophisticated imaging, such as computed tomography or magnetic resonance imaging, should be obtained if plain film is unrevealing but there is high suspicion of fracture.
Figure 3. Diagram showing the types of fracture of the cuboid [1].
Cuboid Fracture Classification:
In 2016, Fenton et al. proposed a classification system for fractures of the cuboid based on the fracture pattern and the mechanism of injury (Fig. 3) [1]. The treatment of these fractures was also described.
Table 1. Summary of the types of fracture of the cuboid, the frequency, mechanism of injury, treatment and outcomes from the literature [1].
Treatment:
A cuboid fracture with comminution, significant ligamentous injuries, or greater than 2mm of step-off at any articular surface should be recommended for surgery [1,4]. An isolated cuboid fracture without these concerning features can be treated nonoperatively. Simple body fractures and nondisplaced avulsion fractures are treated with a below-the-knee weightbearing cast for 6 to 8 weeks or until there are radiographic signs of a bony union [2].
Complications:
Cuboid fractures are frequently associated with other fractures, dislocations, or ligamentous injuries, and missed or mismanaged cuboid fractures can lead to significant complications [2,3,5]. Malunion, degenerative joint disease, persistent subluxation, and prolonged pain are complications of mismanaged cuboid fractures [2]. Degenerative arthritis and disruption of the midfoot biomechanics can result from untreated cuboid fracture [3].
References:
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(7):1003-1008. DOI: 10.1302/0301-620X.98B7.36639
Miller SR, Handzel C. Isolated cuboid fracture. A rare occurrence. J Am Podiatr Med Assoc. 2001;91(2):85-88. DOI: 10.7547/87507315-91-2-85
Grivas TB, Vasiliadis ED, Koufopoulos G, Polyzois VD, Polyzois DG. Midfoot fractures. Clin Podiatr Med Surg. 2006;23(2):323-vi. DOI: 10.1016/j.cpm.2006.01.001
Pinney SJ, Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin North Am. 2001;32(1):21-33. DOI: 10.1016/s0030-5898(05)70191-7
Khatri Chhetri KM, Acharya P, Rokaya Chhetri DR. Combined fracture dislocation of the navicular bone along with cuboid, cuneiform and longitudinal split fracture of the lateral malleolus: a rare combination of fractures. Chin J Traumatol. 2014;17(6):358-360. PMID: 25471434. https://pubmed.ncbi.nlm.nih.gov/25471434/
Corey Brown is a medical student at Meharry Medical College in Nashville, TN. He is vice-president of his school’s radiology interest group and a member of Rad Boot Camp. Prior to medical school, he attended Queens University of Charlotte and the University of Toronto. He graduated with degrees in biochemistry and biomedical engineering. As a graduate student, Corey volunteered at Milestone Christian Ministries and worked with Maple Leaf Sports and Entertainment as a Soccer Senior Sport Lead Coach. He enjoys barbering and watching sports in his free time.
Follow Corey Brown on Twitter @coreybrwn
Kevin M. Rice, MD is the president of Global Radiology CME
Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In both 2016 and 2021, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.
Follow Dr. Rice on Twitter @KevinRiceMD
