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Cuboid Fractures

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Cuboid Fractures By: Philip Parr Ligaments attaching to the Cuboid Superior: The calcaneocuboid band of the bifurcate ligament dorsal calcaneocuboid ligament Inferior ... – PowerPoint PPT presentation

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Title: Cuboid Fractures


1
Cuboid Fractures
  • By Philip Parr

2
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

3
Fractures of the Cuboid
  • Avulsion
  • Body
  • Simple
  • Stress
  • Comminuted/Crush
  • Fractures with dislocation

4
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
5
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.

Miller, R. Isolated Cuboid Fracture A rare
occurrence. J Am Podiatr Med Assoc 91(2) 85-88,
2001
6
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.

Miller, R. Isolated Cuboid Fracture A rare
occurrence. J Am Podiatr Med Assoc 91(2) 85-88,
2001
7
(No Transcript)
8
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.

Miller, R. Isolated Cuboid Fracture A rare
occurrence. J Am Podiatr Med Assoc 91(2) 85-88,
2001
9
Avulsion Fractures
  • Most often occur as a result of tension of
  • Inferior Calcaneocuboid ligament
  • Lateral band of the bifurcate ligament
  • Tarsometatarsal ligaments

Miller, R. Isolated Cuboid Fracture A rare
occurrence. J Am Podiatr Med Assoc 91(2) 85-88,
2001
10
Diagnosis of Cuboid Fractures
  • Plain Film
  • Lateral
  • DP
  • MO best plainfilm view
  • Bone Scan
  • CT
  • MRI

Miller, R. Isolated Cuboid Fracture A rare
occurrence. J Am Podiatr Med Assoc 91(2) 85-88,
2001
11
Treatment
  • Simple body fractures and non-displaced avulsion
    fractures
  • BK Weightbearing Cast for 6-8 wks

Miller, R. Isolated Cuboid Fracture A rare
occurrence. J Am Podiatr Med Assoc 91(2) 85-88,
2001
12
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

MAIN BJ, JOWETT RL Injuries of the midtarsal
joint. J Bone Joint Surg Br 57 89, 1975.
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.
HERMEL MB, GERSHON-COHEN J The nutcracker
fracture of the cuboid body by indirect violence.
Radiology 60850, 1953.
13
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
14
Complications
  • Malunion
  • DJD
  • Persistant subluxation
  • Pes planovalgus

Miller, R. Isolated Cuboid Fracture A rare
occurrence. J Am Podiatr Med Assoc 91(2) 85-88,
2001
15
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.
16
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).

Weber, M and Locher, S. Reconstruction of the
Cuboid in Compression Fracture Short to Midterm
results in 12 patients. FAI 2002.
17
FAI Study
  • 8 of 12 were from MVA
  • 1 from fall from horse
  • 1 crush
  • 1 paraglide
  • 1 sprain

Weber, M and Locher, S. Reconstruction of the
Cuboid in Compression Fracture Short to Midterm
results in 12 patients. FAI 2002.
18
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.

Weber, M and Locher, S. Reconstruction of the
Cuboid in Compression Fracture Short to Midterm
results in 12 patients. FAI 2002.
19
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.
20
FAI Study
  • Operative technique (contd)
  • 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.

Weber, M and Locher, S. Reconstruction of the
Cuboid in Compression Fracture Short to Midterm
results in 12 patients. FAI 2002.
21
FAI Study
  • Operative technique (contd)
  • The lateral wall fragments were then reduced, and
    the construct stabilized using 2 2.0 mm plates
    dorsolaterally and plantarlaterally.

Weber, M and Locher, S. Reconstruction of the
Cuboid in Compression Fracture Short to Midterm
results in 12 patients. FAI 2002.
22
FAI Study
  • Operative Technique (contd)
  • 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.
23
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.

Weber, M and Locher, S. Reconstruction of the
Cuboid in Compression Fracture Short to Midterm
results in 12 patients. FAI 2002.
24
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.

Weber, M and Locher, S. Reconstruction of the
Cuboid in Compression Fracture Short to Midterm
results in 12 patients. FAI 2002.
25
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.

Weber, M and Locher, S. Reconstruction of the
Cuboid in Compression Fracture Short to Midterm
results in 12 patients. FAI 2002.
26
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

Weber, M and Locher, S. Reconstruction of the
Cuboid in Compression Fracture Short to Midterm
results in 12 patients. FAI 2002.
27
The End
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