split in the cuboid with marked disruption of the calcaneocuboid joint. Figure. 1b The postoperative film shows ... the navicular, having complex ligamentous.
DISPLACED
FRACTURES
BRUCE
J. SANGEORZAN,
From
We report
four cases
OF
of fracture
MARC
the University
of the cuboid
THE
F. SWIONTKOWSKI
of Washington,
treated
CUBOID
Seattle
by open
reduction,
bone
grafting
where
and internal fixation. We recommend this treatment where there is appreciable displacement of the articular surfaces. The preliminary results were better than those previously reported treatment or for later midtarsal fusion.
Injuries of the cuboid are avulsion fractures. mond
and
fractures ligament
are uncommon More rarely,
Hastings
1969)
or
are seen (DeLee 1986). attachments, fractures
; the most dislocation
indirect
frequent, (Drum-
compression
Because of its shape and of the cuboid are usually
We
have
of the cuboid, fixation. Three cellous
reviewed
Case motor
Chopart-type 1953).
knee amputation, fractures of the
(Hermel
and
Fig.
Gershon-Cohen
© 1990 British 0301-620X/90/3098 JBoneJoiniSurg[Br]
376
should
Editorial
be sent
to Dr B. J. Sangeorzan.
Society
$2.00 1990;
72-B:
of Bone and Joint 376-8.
1. A 28-year-old vehicle and
male sustained
Surgery
shows a longitudinal postoperative film
After cuboid
displaced
fractures
stabilisation fracture
REPORTS pedestrian was struck by a a traumatic right above-
a left anterior cruciate pelvis, spine, sacrum, and
Fig.
B. J. Sangeorzan, MD, Assistant Professor M. F. Swiontkowski, MD, Associate Professor Harborview Medical Center, University of Washington, Department ofOrthopaedics, 325 Ninth Avenue, Seattle ZA-48, Washington 98104, USA. Correspondence
CASE
Ia
Case 2. Figure la A pre-operative oblique radiograph disruption of the calcaneocuboid joint. Figure 1b The two lag screws.
isolated
by open reduction and internal bone grafts to fill a corticocan-
defect.
associated with other midfoot injuries. Functionally, the cuboid is involved in all the intrinsic movements of the midfoot and hindfoot (Main and Jowett 1975). We could find only one report of cuboid fractures, and this was in injuries
four
all treated required
necessary
of one or more for conservative
lb
split in the cuboid with shows the reduced fracture
was
injury, and left cuboid.
of the treated
marked held by
life-threatening surgically.
injuries,
the
At operation, the distal articular surface was found to be driven into the body of the cuboid. When this was restored to its proper position, a large corticocancellous defect required filling with iliac crest graft, oriented so that The
cortical bone replaced the lateral wall of the cuboid. graft was held with a lag screw and a Kirschner wire THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
DISPLACED
was
used
to stabilise
months
the
the
patient
was
distal
articular
taking
FRACTURES
surface.
his entire
At
weight
with
14 no
symptoms and had full painless movement. Radiographs showed some narrowing of associated joint spaces. Case 2. A 22-year-old woman sustained left acetabular and patellar fractures, and a right-sided cuboid fracture
in a motor
vehicle
she had an open At operation, cuboid
joint
the centre comminuted
accident.
Five
days
reduction of the cuboid the dorsal ligaments
were
intact,
but
of the calcaneocuboid fragments were
the
bone
after
the
split
377
lateral corticocancellous graft and a small plate
The
injury,
cuboid
cuneiform, with the ments.
through
mon.
joint (Fig. la). Some removed and the bone was
reduced and fixed with two 4.0 mm cancellous (Fig. 1 b). At 1 5 months, the patient was walking on this foot and had full painless range of movement.
CUBOID
defect was filled with iliac bone was used as a buttress (Fig. 2c).
DISCUSSION
fracture. of the metatarsowas
OF THE
screws normally midtarsal
articulates
with
the
calcaneus,
the
the fourth and fifth metatarsals and navicular, having complex ligamentous This
but
arrangement dictates
that
makes
isolated
malunion
to indirect
injury
from
forced
injury
is likely
restricted movement. In addition, ical relationship appears to make
lateral
sometimes attachuncom-
to result
in
this complex anatomthe cuboid susceptible
abduction
of the
forefoot,
or a force directed laterally on a fixed forefoot (Main and Jowett 1975 ; Hillegas 1976). The cuboid is best evaluated radiographically
by an oblique
view
.,
(DeLee
1986).
.;
..;
.
Fig.
1
Fig.
2a
2b
Fig.
2c
-
Case 4. Figure 2a The oblique radiograph shows compression of the cuboid with 8 mm shortening of the lateral border of the foot. Figure 2b Kirschner wires were placed into the subchondral bone of the proximal and distal articular surfaces and a laminar spreader used to disimpact the fragments. Figure 2c Reduction was maintained with 3.5 mm screws placed through a 2.5 mm plate acting as a buttress, and the defect was filled with iliac crest graft. The oblique orientation of the radiograph gives the false appearance that the plate had crossed the calcaneocuboid joint.
Case long
3. A 49-year-old axis of the
comminution loose fragments surface
was
man cuboid,
fell and with
sustained some
at the calcaneocuboid were removed, and elevated
and
packed
a split crushing
in the and
joint. At operation, the depressed dorsal
with
cancellous
grafts.
The Hermel
treatment ofdisplaced and Gerson-Cohen
fractures is controversial. (1953) suggest that commi-
nution requires primary midtarsal fusion and that early arthrodesis may decrease the period of morbidity. They consider that this fusion should not give rise to an
The fracture was fixed with two screws; the unstable metatarsocuboid joint being held with a percutaneous pin for six weeks. The patient returned to work on a farm at six months and has no complaints after one year.
appreciable disturbance in gait since “the lateral aspect of the foot is primarily rigid and static”. By contrast, Hillegas (1976) emphasised that the cuboid articulates with five other bones and is an important stabiliser of the
Case 4. A 19-year-old man jumped from a third floor window. He felt his foot ‘pop’ as it was ‘forced outward’.
lateral aspect of the foot. He also was likely to lead to discomfort
He had sustained a crush injury of the cuboid (Fig. 2a). At operation, using a longitudinal incision between extensor digitorum brevis and the peroneal tendons, reduction was performed by placing Kirschner wires into the subchondral bone of the proximal and distal frag-
fitting
ments
results
VOL.
and 72-B,
using
No. 3, MAY
a laminar 1990
spreader
(Fig.
2b).
The
large
and
advocated
accurate
stressed that and difficulty reduction
and
malunion in shoe internal
fixation, citing the good results achieved by open reduction ofa pure dislocation (Drummond and Hastings 1969; Hillegas 1976). Main and Jowett (1975) report only fair to poor in four
patients
treated
conservatively;
all four
B. J. SANGEORZAN,
378
required reduction
a triple arthrodesis later. They with internal fixation. DeLee
M. F. SWIONTKOWSKI
recommend open (1986) considered
that residual displacement of the articular surfaces of the cuboid could result in persistent subluxation of the midtarsal joint, and recommended open reduction and grafting; he suggested that long-term degenerative changes Our
were
likely
findings
if reduction in four
cases
is not
achieved.
support
the
concept
defects
grafting. satisfactory.
Our
early
Even anatomy
where of the
clinical
large and
enough
to require
radiographic
there is considerable articular surface
can
results
comminution, be restored
We
with believe
structural iliac graft and that less aggressive treatment
use of early or late satisfactory results. No benefits commercial article.
in any party
arthrodesis
form have been related directly
that
compression between the anterior calcaneus and the metatarsals is the usual mechanism of injury. In three of our cases, the proximal or distal articular surface was driven into the centre ofthe bone, and reduction revealed corticocancellous
maintained fixation.
the and
likely
to give
received or will be received or indirectly to the subject
less
from a of this
REFERENCES DeLee
JC. Surgeri
Drummond report Hermel
bone are
are
internal or the
MB, indirect
Fractures ofthefoot.
and dislocations of the foot. In : Mann St. Louis, etc : CV Mosby Co. 1986.
DS, Hastings DE. Total dislocation of a case. J Bone Joint Surg [Br] 1969
of the cuboid 5 1 -B :716-8.
Gershon-Cohen J. Nutcracker fracture violence. Radiology. 1953 ; 60:850-4.
Hil.legas
RC. Injuries to the midfoot : a morbidity. In: Bateman JE, ed. Foot WB Saunders Company, 1976:266-71.
Main
;
BJ, Jowett 1975; 57-B
RL. Injuries :89-97.
THE
major science.
of midtarsaljoint.
JOURNAL
OF BONE
RA,
of the
bone:
cuboid
by
cause of industrial Philadelphia, etc:
J Bone
AND
ed.
Joint
JOINT
Surg
[Br]
SURGERY
