displaced fractures of the cuboid - CiteSeerX

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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