Understanding Cuboid Fractures: Anatomy, Causes and Symptoms

Cuboid fractures of the foot, although uncommon, can cause significant pain and deformity if not treated. In this article, we’ll discuss the anatomy, causes, and symptoms of cuboid fractures. 

Cuboid Anatomy

The cuboid bone is a “wedge-shaped” bone on the lateral aspect (outside portion) of the midfoot. It makes up one of the tarsal bones on the lateral column of the foot. It is a non-weight bearing bone. It helps provide support to the outside of the foot. 

The cuboid articulates with the calcaneus (heel bone) and the fourth and fifth metatarsals. In some people, it may also articulate with the navicular bone as well. 

There is a groove present on the plantar surface (bottom) of the cuboid in which the peroneus longus tendon passes. This is called the “peroneal sulcus”.

The lateral plantar artery provides blood supply to the cuboid bone. The sural nerve innervates the cuboid bone. 
There are strong ligaments that attach into the bone including the short and long plantar ligaments. 

Cuboid Fracture Incidence

Cuboid fractures are rare. The incidence of midfoot fractures is 3.6/100,000. From these, half are cuboid fractures (1).

Cuboid fractures are rare because it is a non-weight bearing bone, so it is not susceptible to the same stress as other foot bones. Also, the cuboid is protected by strong ligaments, making it difficult to fracture. 

Cuboid Fracture Classification

Cuboid fractures are classified into three main categories by the Orthopaedic Trauma Association. 

Group A fractures: Extra-articular fractures (fractures that occur outside the joint)

Group B fractures: Metatarsocuboid joint fractures or Calcaneocuboid joint fractures

Group C fractures: Fractures involving both the metatarsocuboid joint and the calcaneocuboid joint

Cuboid Fracture Types and Mechanism of Injury

Extra-Articular Fractures

These fractures involve fractures of the cuboid bone that occur outside of the joint surfaces. These fractures often occur in the body of the cuboid bone, but can occur anywhere. Dorsal cuboid fractures and lateral fractures can be extra-articular.

This type of fracture is typically caused by a direct blow or a twisting injury to the foot. Extra-articular fractures can be displaced (fracture fragments are shifted) or non-displaced (fracture is present but is in proper alignment).

Intra-Articular fractures

Intra-articular fractures are fractures of the cuboid bone that extend into the tarsometatarsal joint or the calcaneocuboid joint. These types of fracture can occur due to high impact trauma or force, such as a fall from a height or a motor vehicle accident. Athletic injuries can also cause these fractures.

Fractures that involve the joint can be displaced or non-displaced. Cuboid joint dislocation may be present as well. 

Comminuted Cuboid Fractures

Traumatic injury, such as a fall from height, and high energy blunt trauma crush injuries can result in comminuted cuboid fractures. Comminuted cuboid fractures mean that the cuboid is broken in more than two fragments.

Avulsion Fractures

Cuboid avulsion fractures are extra-articular fractures that occur when a piece of bone is avulsed due to ligament injury. Cuboid avulsion fractures can occur from ankle injuries (such as ankle sprains). The twisting injury of the foot that occurs during an ankle sprain/ankle injury can cause a cuboid avulsion fracture. 

Isolated Cuboid Fractures

Isolated cuboid fractures are rare, but can occur from an axial load being applied to an abducted foot that is plantarflexed. Axial load is like a kind of pressure. It means pushing down on the foot.  Abducted means moving the foot away from the center of the body, and plantarflexed means pointing the toes down. 

This type of injury can crush the cuboid bone resulting in a cuboid crush injury.  This is referred to as a “Cuboid Nutcracker fracture”. 

Cuboid Stress Fractures

Cuboid stress fractures can occur due to activities that involve repetitive stress to the midfoot, such as running. These fractures are often seen in athletes. Isolated cuboid stress fractures can also occur more often in people who have osteoporosis in the bones of the foot. 

Cuboid Fracture Symptoms

Cuboid fractures symptoms can vary. 

Some of the symptoms of cuboid fractures include:

• Lateral foot pain
• Swelling on the outside of the foot
• Bruising on the outside of the foot
• Inability to bear weight on the affected foot
• Limping when walking
• Pain when pressure is applied to the outside of the foot
• Pain relief with rest
• Visible deformity of the foot
• Grinding sound when moving the foot
• Pain with plantar flexion of the foot
• Limited range of motion in the midfoot
• Numbness/Tingling sensation
• Weakness

Identifying and diagnosing cuboid fractures can be difficult. It’s important to visit your local foot doctor if you believe you may have sustained a cuboid fracture so that you can receive appropriate treatment.

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References

1.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/)

2. 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/. The patterns of injury and management of cuboid fractures: a retrospective case series.

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/

Nutcracker Cuboid Fracture: A Case Report and Review

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/

5. 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://pubmed.ncbi.nlm.nih.gov/30788224/

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