High Yield Topics

Cuboid Subluxation and Fracture

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Ovid: 5-Minute Sports Medicine Consult, The


Cuboid Subluxation and Fracture
Aaron P. Leininger
Danielle L. Mahaffey
Karl B. Fields
Basics
Description
  • Subluxation and dislocation: Midfoot injury that disrupts the ligamentous structures around the cuboid, allowing subluxation and, rarely, complete dislocation of the cuboid. Typically, subluxation and dislocation occur in the plantar direction, but one case of dorsal subluxation (1)[C] has been reported. Mechanism of injury is often an inversion ankle sprain, although alternative mechanisms have been described (2)[A].
  • Fracture: Typically, tarsal cuboid bone fractures arise from indirect “nutcracker” compression, usually after significant traumatic force that causes abduction of the forefoot. Other types of cuboid fractures include avulsion fractures and stress fractures.
  • Synonym(s):
    • Subluxation and dislocation: Cuboid syndrome; Locked cuboid; Dropped cuboid; Calcaneal cuboid fault syndrome; Lateral plantar neuritis
    • Fracture: Nutcracker fracture
Epidemiology
Incidence
  • Subluxation: Subluxation is considered rare, but some propose that it is underdiagnosed. 2 studies found the prevalence of cuboid instability to be 4–6.7% in patients with foot problems and inversion injury, respectively (3,4)[B].
  • Dislocation: Rare
  • Fracture: Rare; in one study, 38% (58/155) of traumatic midfoot fractures involved the cuboid (5)[C].
Risk Factors
  • Subluxation:
    • Pronated feet
    • Tight peroneal longus tendon
    • Ballet dancing (2)[A]
    • Trail running or running on uneven surfaces
  • Fracture and dislocation:
    • Activities at high risk for foot trauma (eg, motorsports, equestrian, etc.)
    • Long-distance running (stress fracture)
Diagnosis
History
  • Subluxation:
    • May follow inversion ankle injury
    • Subluxation may be precipitated by increased routine activity, increased activity on uneven terrain, or initiation of new activity, especially for patient with excess pronation.
    • Pain in lateral midfoot proximal to and involving the base of the 4th and/or 5th metatarsal, exacerbated with activity
    • Often with symptom-free intervals
    • Associated with foot weakness or difficulty with ambulation
  • Fracture and dislocation:
    • Substantial traumatic force needed owing to stable ligamentous attachments
    • Most patients with fractures are unable to bear weight.
    • Dislocations often are associated with severe weakness and markedly antalgic gait if patient is able to bear weight.
    • Midfoot deformity may be present with fracture or dislocation.
Physical Exam
  • Subluxation:
    • Tenderness to palpation over cuboid (dorsal and/or plantar surface)
    • Increased mobility to manipulation of the cuboid at the Lisfranc joint
  • Dislocation and fracture:
    • Midfoot swelling
    • Tenderness to palpation over cuboid (dorsal and/or plantar surface)
    • With dislocation, abnormal indentation in lateral midfoot may be noted with concomitant fullness in the plantar surface.
    • May be unable to bear weight
Diagnostic Tests & Interpretation
Imaging
  • Radiographs: Recommend anteroposterior, lateral, and oblique views.
    • Oblique view usually demonstrates a cuboid fracture, and dislocation can be seen if medial border of 4th metatarsal is not aligned to medial border of the cuboid.
    • Subluxation often is not seen.
  • CT scan is often beneficial if fracture is present.
  • MRI is the most sensitive test for stress fracture.
Differential Diagnosis
  • Peroneus longus tenosynovitis
  • Base of 4th and 5th metatarsal stress fracture
  • Calcaneonavicular coalition
  • Peroneal longus tendon subluxation
  • Os peroneum fracture

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Treatment
  • Subluxation:
    • Literature suggests repeated manipulation with the “cuboid whip” or “cuboid squeeze” attempting to reestablish proper alignment of the calcaneocuboid joint. One case series of 7 patients reported good results with this technique (6)[C].
    • Patient stands with support, affected leg with knee bent to 90 degrees. Examiner grasps forefoot with fingers and places thumbs (one over the other) on plantar aspect of cuboid. Cuboid is manipulated with a quick downward thrust of the thumbs in a dorsal and lateral direction.
    • Orthotics, use of cuboid pad, and arch straps/taping recommended (2)[C]
    • Strength and proprioception rehabilitation (2)[C]
  • Dislocation:
    • Controversial
    • Open fixation followed by short-leg splinting/casting and non-weight-bearing for 6 wks or more depending on stability (7)[C]
    • Closed reduction with local anesthesia (7)[C]
  • Fracture:
    • Controversial
    • Open reduction with internal fixation, possibly requiring a bone graft, is the most commonly accepted treatment (8)[C].
    • Other options include conservative treatment with cast immobilization for 6–8 wks, surgical arthrodesis, and external fixation (9)[C].
Ongoing Care
  • Subluxation:
    • Return to play depends on the severity of the athlete's symptoms.
    • Most athletes should be able to return to play almost immediately given proper treatment with orthotics/cuboid pad/arch supports.
    • Some patients may need a period of relative rest with return to play after physical therapy and symptom improvement.
    • Some patients also learn to self-treat in the field after instruction in self-administration of the cuboid whip maneuver.
  • Fracture/dislocation:
    • Return to play for cuboid stress fractures is similar to other foot stress fractures.
    • Athletes should follow a slow, incremental, symptom-free return-to-play protocol with rest and regression of intensity of symptoms develop.
    • Return to play for most fractures and dislocations should proceed only after clearance by the orthopedic surgeon and would be slow and incremental.
    • Depending on the severity of the injury, there may be chronic damage ultimately limiting return to play.
    • Athletes who underwent ankle arthrodesis will be very limited in the types of sports they can play because of lack of motion at the ankle joint.
Complications
  • Subluxation and dislocation: Chronic instability can be a problem for both dislocation and subluxation.
  • Fracture: Nonunion, particularly if diagnosis/treatment is delayed
References
1. Mooney M, Maffey-Ward L. Cuboid plantar and dorsal subluxations: assessment. J Orthopaed Sports Phys Ther. 1994;20(4):220–226.
2. Patterson SM. Cuboid syndrome: a review of the literature. J Sports Sci & Med. 2006;(5):597–606. Available at: http://www.jssm.org/vol5/n4/18/v5n4–18pdf.pdf
3. Newell SG, Woodle A. Cuboid syndrome. Phys Sports Med. 1981;9:71–76.
4. Blakeslee TJ, Morris JL. Cuboid syndrome and the significance of midtarsal joint stability. J Am Podiatr Med Assoc. 1987;77:638–642.
5. Richter M, Wippermann B, Krettek C, et al. Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int. 2001;22:392–398.
6. Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series. J Orthop Sports Phys Ther. 2005;35:409–415.
7. Littlejohn SG, Line LL, Yerger LV Jr. Complete cuboid dislocation. Orthopedics. 1995;19:175–176.
8. Sangeorzan BJ, Swintkowski MF. Displaced fractures of the cuboid. J Bone Joint Surg. 1990;72-B:376–378.
9. Manoj-Thomas A, Gadgil A. Nutcracker fracture of the cuboid: a case report. Eur J Orthop Surg Traumatol. 2006;16:178–180.
Additional Reading
Hunter JC, Sangeorzan BJ. A nutcracker fracture. Am J Roentgenol. 1996;4:888.
Main BJ, Jowett RL. Injuries of the midtarsal joint. J Bone Joint Surg. 1975;57-B:89–97.
Omey ML, Micheli LJ. Foot and ankle problems in the young athlete. Med Sci Sports Exerc. 1999;31:S470–S486.
Codes
ICD9
  • 825.23 Fracture of cuboid bone, closed
  • 838.01 Closed dislocation of tarsal (bone), joint unspecified


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