Sunday, March 03, 2024
INJURIES Middle of Foot Injuries

Cuboid Fractures of the Foot- A Helpful Guide

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Anatomy of the Cuboid Bone

The cuboid is a “cubical-shaped bone” on the outside portion of the midfoot. The cuboid is located between the calcaneus (heel bone) and the fourth and fifth metatarsal bones. 

Although the cuboid bone is not a direct weight-bearing bone, its function is very important because it helps provide stability to the foot when standing and walking.   

An important tendon called the peroneus longus tendon (that helps evert the foot) courses along the bottom of the cuboid bone before it inserts into the foot. The cuboid bone helps the tendon glide by acting as a fulcrum. Ligaments also connect the cuboid to its adjacent bones. 

Injuries to the cuboid can affect all these soft tissue structures and cause instability.

It’s important to understand the anatomy and the impact it can have on cuboid injuries.

Cuboid fractures should be managed quickly and accurately to ensure the best outcomes. In this article, we’ll discuss the details of cuboid fractures and how they are managed. 

How Does a Cuboid Fracture Occur?

Cuboid fractures can occur due to direct high-impact crush injuries in the foot, such as car accidents, or falls from heights.

Cuboid fractures can also occur when something heavy falls on the foot. The cuboid bone gets crushed and this is referred to as a “Nutcracker Cuboid fracture”

Isolated nutcracker fractures are rare. If you have a cuboid fracture, other bones in the foot may be broken as well. 

In many cases, cuboid fractures occur alongside ankle sprains and ankle fractures. 

Occasionally, cuboid fractures can occur due to repetitive stress. This can cause a cuboid stress fracture. This is seen more often in athletes and young children.  

outside of foot swelling

What Are the Symptoms of a Cuboid Fracture?

Symptoms of cuboid fractures can vary. Some of the common symptoms include: 

  • Pain with pressure on the outside portion of your foot
  • Swelling with bruising on the outer midfoot
  • Fracture blisters may be present 
  • Inability to bear weight on the foot
  • Limping when attempting to walk
  • Gradual, dull achy pain (in the case of a stress fracture)

How Is a Cuboid Fracture Diagnosed?

You will need to see a foot doctor or go to the emergency department if you suspect that you have sustained a cuboid fracture.

Your doctor will order x-rays to assess the foot and evaluate the fracture.

In some cases, your doctor may order advanced imaging such as Magnetic Resonance Imaging Scan (MRI) or Computed Tomography scan (CT) to view the cuboid bone in more detail. These tests can provide more detailed images of the foot and can help identify the fracture. These advanced imaging tests can also help locate injuries to adjacent bones, muscles, and ligaments in the foot.

When a fracture of the cuboid occurs, it is either non-displaced (broken but in proper position), or displaced (broken and with a gap between the fracture fragments). 

Your doctor will check to see if the fracture is comminuted (multiple pieces) and if the fracture extends into the joint.

Your doctor will also check to see if the cuboid bone is compressed due to the fracture. This is all important when it comes to determining what treatment you may need. 

What Is the Treatment For A Cuboid Fracture?

If you suspect you may have fractured your cuboid, start RICE therapy immediately.  Resting and icing the foot can help reduce pain and inflammation in the area. Try to stay off your foot until you are able to be evaluated by your doctor. 

Cuboid fracture treatment will depend on the fracture pattern and the patient.

cast boot

Non-displaced Cuboid Fractures

If your cuboid bone is non-displaced (broken but in proper alignment), your doctor will suggest that you stay non-weight bearing in a below knee cast or cast boot to the affected foot for 6 weeks minimum. This is because it takes 6-8 weeks for bone fractures to heal. 

You can find a comfortable cast boot on Amazon. You can also use a knee scooter to help you stay off of your foot. Crutches can also be used, but knee scooters are helpful for people who struggle with balance issues. 

Non-displaced fractures don’t require fixation and will generally heal after several weeks.

Your doctor will see you every 3-4 weeks to obtain repeat x-rays to see if the cuboid bone is healing. When the bone is healed, your doctor will recommend you transition to athletic shoes. This is usually possible around 8-10 weeks after the fracture. 

When you do start walking, you may notice increased swelling due to blood pooling in the foot. You will need to get medical-grade compression stockings (strength 15-20mmHg) to reduce swelling. 

Compression stockings can be worn during the day on both legs and removed at night. They are effective in helping reduce swelling. I prefer the Jobst 15-20mmHg compression stockings from Amazon. One pair of socks should last for 6 months.  

Make sure you do not wear compression stockings if you have peripheral vascular disease (poor blood flow in the legs). 

Stress Fractures of the Cuboid

Isolated cuboid stress fractures are rare, but can happen. These injuries occur due to repetitive strain on the lateral aspect (outside portion) of the foot. 

Stress fractures can happen from activities such as marching, jumping, dancing, and sports injuries.

Cuboid bone stress fractures can be difficult to diagnose, because they often do not show up on x-ray immediately. 

Isolated stress fractures can be even harder to visualize. Your doctor may choose to order an MRI or CT scan to help identify the presence of a fracture. 

Ultrasound can be beneficial as well in confirming the presence of a stress fracture.

Cuboid stress fractures ultrasound would reveal a crack of the cuboid bone as well as swelling in the area of injury. 

Symptoms of stress fractures include lateral foot pain, foot swelling, bruising, and limping when walking.  

If you have a hairline crack in the cuboid from a stress fracture, your doctor will suggest you wear a cast boot and remain non weight bearing for 4-6 weeks. 

This can be followed by gradual weight bearing in athletic shoes. Stress fracture activity should be limited until you can comfortably walk without pain. 

Displaced Cuboid Fractures

If the cuboid bone is comminuted (multiple fragments) with greater than 3mm of space between fracture fragments, you will need surgery. 

This is because when the cuboid bone breaks and displaces, the cuboid bone becomes compressed and doesn’t articulate properly with its adjacent bones.

An extensive fracture line that extends into the joint can cause painful chronic arthritis. This is often seen with a cuboid nutcracker fracture.

surgery

Surgery for Cuboid Fractures of the Foot

Your doctor will perform surgery under anesthesia in the operating room. He/she will reduce the cuboid fracture and secure it using plates/screws. Your doctor may add bone graft in the cuboid if there are any voids to fill.

Your doctor may also choose to repair your fracture using a device called an external fixator. This is a frame that helps stabilize the fracture. 

After surgery, you will need to stay off of your feet for 6 weeks to 8 weeks minimum in a cast or cast boot. Your doctor will obtain serial x-rays in the office every 3-4 weeks to assess healing. 

Complications of Cuboid Fracture Surgery

Surgery to reduce cuboid fractures has a high success rate. However, like with any surgery, complications can happen.

Some of the complications that can occur from surgery include:

Non-union

A nonunion means failure of the normal fracture healing process, meaning that the fracture does not heal in a normal time frame. Nonunions can cause continued pain in the foot and a loss of function due to this. 

If you have a non union, your doctor may recommend an external bone stimulator. A bone stimulator is a machine you wear for 20 minutes-1 hour a day near the fracture site. A bone stimulator uses electrical pulses to stimulate the body to heal broken bones.

Another option is surgery to fix the nonunion. Your doctor may use a bone graft to help promote bone healing at the site of the fracture. 

Infection

Occasionally, surgical incision sites can become infected. Signs of infection can include redness, swelling, fever, and drainage. If an infection is suspected, it is important to seek medical attention right away to prevent it from becoming more serious. Your doctor will prescribe antibiotics to treat the infection. 

In some cases, the cuboid bone itself can become infected. In this case, stronger IV antibiotics may be needed to treat the infection. 

Nerve damage

During surgery, nerve damage can occur. Nerve damage can be temporary or permanent. Nerve damage can cause numbness or tingling in the foot. Your doctor will prescribe pain medication to help treat the nerve damage and keep you comfortable. 

Hardware problems

Plates and screws are used to fix a broken cuboid bone. Occasionally, hardware can become loose or fail completely. In these cases, your doctor will recommend surgery to remove the hardware and replace it. 

Arthritis

If the cuboid fracture line extends into the joint space, post-operative arthritis pain may be present. This can cause dull, achy pain in the midfoot joints. This can also cause the midfoot to feel stiff. 

Recovery for Cuboid Fractures

Recovery from a cuboid fracture can take several weeks or months, depending on the severity of the fracture. 

The first step in the recovery process is for the patient to rest and minimize physical activity until the fracture is healed.

Regardless of the type of fracture, patients can expect to remain non-weight bearing on the surgical foot for a minimum of 6 weeks. If the patient underwent surgery, they will then need to remain partially weight bearing in a protected cast boot for another 4 weeks prior to transitioning to regular shoes. 

The patient may need to wear a cast or supportive boot to protect the foot and help keep the bones in alignment.

Ice, elevation, and anti-inflammatory medications such as Motrin can be used to reduce swelling and pain. Your doctor will prescribe pain medication to help keep your pain under control. 

Physical therapy is usually recommended to help improve range of motion and strength in the foot and ankle after the cuboid fracture has healed. This is because being off of the foot for several weeks can weaken the leg muscles and affect your gait. 

Exercises such as ankle circles, heel slides, and calf raises can help improve flexibility and strength. It is important to follow the physical therapist’s instructions and progress slowly to avoid any further damage to the affected area. 

Recovery from a cuboid fracture can be a long and difficult process, but with proper treatment and rehabilitation, the patient can eventually return to their normal activities. It is important to follow the advice of your doctor and physical therapist to ensure a complete and successful recovery.

Should You Wear a Walking Boot All Day?

Check with your doctor first. In general, you should wear a cast boot during the day, but it can be removed in the evening while you are resting and off the foot. Keep the leg elevated on pillows to reduce swelling when you remove the boot. You can also remove the boot when showering. 

You may be able to return to an athletic shoe after 10-12 weeks depending on how the bone is healing. 

hiking boots

Will Walking on a Fractured Cuboid Make It Worse?

Walking on a displaced fracture can cause it to displace further and worsen the deformity present in the foot. Not only that, walking can slow healing time due to the weight-bearing forces present at the fracture site. It is important to stay off of your foot after cuboid surgery to prevent complications. 

driving foot
Can You Drive With a Cuboid Fracture?

It may take 3 months before you are fully able to drive comfortably. This is because when you sustain a fracture, it takes a minimum of 6-8 weeks for the bone to heal. Not only that, you may struggle to walk for a while after your bone heals due to weakness of your leg muscles. 

You may need physical therapy to help you walk normally. When you can walk comfortably, you should be able to drive. 

If the fracture occurred in the foot that you don’t use to drive, you will need to speak to your doctor to see if it would be appropriate for you to drive. 

You should never drive with a cast on. You should also never drive while taking narcotics. This can increase your risk for an accident. 

What Happens if a Cuboid Fracture Is Left Untreated?

A cuboid fracture is a serious injury and should be treated as such. Long term complications can occur if the cuboid fracture is left untreated. Chronic instability of the midfoot joints and pain can occur.

The instability caused by the fracture can lead to further injury and damage to the surrounding soft tissues, such as ligaments, tendons, and muscles. This can cause additional pain and can limit or even prevent normal movement of the foot.

Chronic pain from an untreated fracture can make it difficult to bear weight on the foot and walk. This can decrease the quality of your life. 

Untreated cuboid fractures can also cause deformity of the foot due to improper healing. The structure of the foot can change and cause foot pain. 

Conclusion

If you suspect you have a cuboid fracture, it’s important to see your doctor right away. Diagnosing cuboid fractures early can prevent displacement of the fracture fragments and also prevent further damage to the foot. This, in turn, will speed up the recovery process and ensure that you become pain-free. 

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cuboid pin

References

  1. Angoules AG, Angoules NA, Georgoudis M, Kapetanakis S. Update on diagnosis and management of cuboid fractures. World J Orthop. 2019 Feb 18;10(2):71-80. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379735/
  2. Pountos I, Panteli M, Giannoudis PV. Cuboid Injuries. Indian J Orthop. 2018 May-Jun;52(3):297-303. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5961267/
  3. Fenton P, Al-Nammari S, Blundell C, Davies M. The patterns of injury and management of cuboid fractures: a retrospective case series. Bone Joint J. 2016 Jul;98-B(7):1003-8. https://pubmed.ncbi.nlm.nih.gov/27365481/
  4. Lucerna A, Espinosa J, Butler N, Wenke A, Caltabiano N. Nutcracker Cuboid Fracture: A Case Report and Review. Case Rep Emerg Med. 2018 Apr 3;2018:3804642. https://pubmed.ncbi.nlm.nih.gov/29850286/

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Vaishnavi Bawa
Dr. Vaishnavi Bawa is a Podiatrist who specializes in treating foot and ankle pathology. LifesLittleSteps mission is to educate the public about foot health in an easy-to-understand manner using evidence-based medicine.
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