CUBOID FRACTURE

Introduction

The cuboid bone lies on the lateral side of the foot, in front of the calcaneus, and behind
the fourth and fifth metatarsal bones.

Isolated fractures of the cuboid are uncommon, and can be difficult to diagnose.

They are more commonly part of more complex injuries, including the Lisfranc fracture-
dislocation of the mid-foot.

CT scan is often required to confirm the diagnosis and is usually required to fully assess
the extent and nature of the injury, even when found on plain radiographs.

Inadequately treated fractures of the body of the cuboid can lead to chronic disability.

Anatomy

The cuboid bone, showing its relations within the foot, (Gray's Anatomy, 1918).

The cuboid forms an important structural element of lateral column of the foot.
The peroneus longus tendon courses along the plantar surface of the cuboid bone in a
lateral to medial direction.

See also Appendix 1 below

Mechanism

Mechanisms of cuboid injury include:

Minor fragmental avulsion fractures at ligament and capsule insertions are the
most common form of cuboid injury.

Direct trauma:

Isolated fractures of the body are uncommon and are usually the result of
direct trauma

Indirect trauma:

One particular injury pattern has been termed the nutcracker fracture.2
This results from an indirect compression force where the cuboid is
crushed between the calcaneum and 4th and 5th metatarsals by axial
torsional forces applied to the plantar-flexed foot

More commonly cuboid fractures are seen in conjunction with other more
complex injuries of the foot, such as the Lisfranc fracture-dislocation of the
forefoot.

Stress fractures may be seen occasionally as sports injuries

This type of injury can occur as a result of normal stresses on abnormal

bone, or as a result of abnormal stresses on normal bone.

Occasionally they can take the form of (depending exactly on how one defines
these injuries) a Toddlers fracture.

Classification

Cuboid fractures can be classified in broad terms as: 1

1. Avulsion fractures.

2. Body fractures:

Simple

Stress
 Comminuted

Crush.

Complications

Complications include:

Compartment syndrome is an important acute complication of midfoot fractures

in general.

Chronic:

Instability with loss of the normal architecture of the lateral arch.

Chronic dysfunction of the peroneus longus, when the peroneal sulcus is

damaged.

Post-traumatic secondary arthritis

Clinical Features

Injuries to the cuboid may be subtle and can be misdiagnosed as lateral ankle sprains.

Pain is a constant feature at the lateral margin of the foot.

There may be point tenderness over the region of the cuboid (in distinction to the lateral
malleolus in ankle injuries). This must provide for an index of suspicion for the
injury, even if plain radiology is normal.

Swelling and bruising may be present, but may not be depending on the exact nature and
extent of the injury.

Weight bearing may be difficult or impossible.

Investigations

Plain radiography

Plain radiography may make the diagnosis, however the fracture may be very difficult to
detect, and so if clinical suspicion is high, CT scan or MRI are further imaging options

Routine views include A-P and lateral views of the foot.

Additional medial oblique views of the foot may be required to see these fractures.

The Os Peroneum, should not be confused with a fracture of the cuboid.

The os peroneum is an small oval accessory ossicle located within the substance of the
distal peroneal longus tendon as it courses near the cuboid bone. It may be confused for
a fracture, but the margins are smooth, rounded and have sclerotic margins. Fractures of
the os itself are possible.

CT scan

This is done to detect occult fractures of the cuboid bone, when plain radiographs are
inconclusive.

CT may also be done to more fully define the extent of a cuboid injury, often not
apparent on plain radiography and to assess for possible occult fractures to adjacent
bones.

MRI Scan

This is useful for the detection of occult fracture, not seen on plain radiography.

It has the advantage over CT scan of better definition of associated soft tissue structures,
such the ligaments, joint capsules and nearby tendons of the peroneus muscles

Bone scan

This is sensitive for occult fractures, not apparent on plain radiography, but is not as
specific as CT scan or MRI.

Management

Diagnosis and treatment of subtle cuboid fractures is important to minimize long term
disability.

Minor cortical avulsion fractures can be allowed to weight bear immediately in a walking
boot, or a back slab and crutches if there are significant symptoms for 2-3 weeks
Simple non-displaced body fractures can generally be treated with a below knee plaster
cast for 6 to 8 weeks or longer until there are radiographic signs of a bony union.

More complex injuries than this will usually require operative management such as
ORIF.

The exact type of surgery required is based on a variety of factors including the degree of
articular incongruity, the presence of subluxation or dislocation, loss of lateral column
length, and associated foot fractures.

Severely comminuted fractures may require arthrodesis.

Disposition

Most cuboid fractures, unless very minor avulsion injuries, should be referred to
Orthopaedics, as even relatively minor disruptions of the cuboid can result in significant
long term arthritis and disability.
Appendix 1

Anatomy of the Cuboid bone:

The left cuboid, Antero-medial view, (Gray's Anatomy, 1918)

The left cuboid, Postero-lateral view, (Gray's Anatomy, 1918)

Appendix 2

Radiology of the foot:

Appendix 3

The Columns of the Foot

The longitudinal arches (or columns) of the foot;

Medial:

1st metatarsal, Medial cuneiform, Navicular, Talus

Middle:

2nd and 3rd Metatarsals, Middle and Lateral Cuneiforms, Navicular, Talus

Lateral:

4th and 5th Metatarsals, Cuboid, Calcaneum

References

1. Miller R.S, Handzel C; J Isolated Cuboid Fracture: A Rare Occurrence; Am

Podiatr Med Assoc 91(2): 85-88, 2001.

2. Hermel M.B, Gershon-Cohen J; The nutcracker fracture of the cuboid body by

indirect violence. Radiology 60: 850, 1953.

3. Borelli J, et al. Fracture of the Cuboid; J Am Acad Orthop Surg 2012;20: 472-477.

Dr J. Hayes
August 2012