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INJURIES Middle of Foot Injuries

Cuneiform Fracture: Causes, Diagnosis & Treatment of Cuneiform Fractures

An isolated cuneiform fracture is rare, but can occur. When cuneiform fractures occur in the foot, they are often a missed diagnosis. Cuneiform fractures can occur from direct or indirect trauma. 

In this article, we’ll discuss everything you need to know about identifying, diagnosing, and managing cuneiform fractures in the foot.

Let’s dive in…

Anatomy of the Cuneiform Bones in the Foot (Medial, Intermediate, and Lateral Cuneiform)

The cuneiforms are the wedge-shaped bones that are located on the inner midfoot.

There are three cuneiform bones: the medial cuneiform, the intermediate cuneiform, and the lateral cuneiform. 

The cuneiform bones exist between the navicular and metatarsal foot bones and are connected to them by strong ligaments. 

The blood supply to the cuneiform bones is excellent. They are supplied by the dorsalis pedis artery on the top of the foot and the medial plantar artery on the bottom of the foot. They also have additional collateral vessels that supply the bones.

What Do the Cuneiform Bones Do?

The cuneiform bones make up the medial (inside) midfoot. They help provide stability to the midfoot while you are walking and running. 

The cuneiform bones are tightly secured to each other with ligaments. There is some motion present between the bones. This helps reduce shock absorption and helps with foot propulsion.

What Causes Cuneiform Fractures?

Isolated cuneiform fractures are rare and comprise 1.7% of all tarsal fractures (1).

Cuneiform fractures occur when an object falls on the midfoot, causing one or more of the cuneiform bones to break. Fractures of the cuneiform can also occur after falling from a height and motor vehicle accidents.

Cuneiform stress fractures can occur due to repetitive stress being placed on the cuneiform bones. Such activities that cause repetitive stress on the cuneiform bones include running, hopping, marching, and dancing. 

Sudden severe plantarflexion (foot and toes flexed in a downwards direction) injury can cause dislocation of the cuneiform. This type of dislocation is more often seen in the intermediate cuneiform due to its position in the midfoot. 

Say for instance you are wearing high heels and accidentally trip and sustain a plantarflexion injury. This could cause your cuneiform bone to dislocate. 

Cuneiform fractures are often associated with other fractures in the foot, such as a Lisfranc Fracture dislocation.

middle of foot pain

How Do You Know if Your Cuneiform Bone Is Broken?

Foot pain symptoms can sometimes be vague. If you have a cuneiform fracture, common symptoms you may experience include:

  • Pain and throbbing in the midfoot (more commonly in the inner midfoot)
  • Swelling in the midfoot/ankle
  • Inability to bear weight on the foot
  • Bruising
  • Pain that worsens with activity and does not get better with rest

How Are Cuneiform Fractures Diagnosed?

If you experience midfoot pain that occurred after trauma or you suspect that you have developed a stress fracture, you should stay off of your foot and contact your local foot doctor. 

Walking on a cuneiform fracture can cause the fracture to worsen. 

Your doctor will perform a history and physical exam. Your doctor will order an x-ray of the foot to determine whether the cuneiform bone is fractured. 

Sometimes, it can be difficult to visualize cuneiform fractures on an x-ray. Normal variations in the cuneiform (like in the case of a bipartite medial cuneiform bone) can look like a fracture, when it is not. 

If the fracture is hard to see, your doctor may order a Magnetic Resonance Imaging test (MRI). 

An MRI can identify a cuneiform fracture along with any soft tissue injuries that could have occurred during the injury. 

If your doctor suspects that there are multiple other fractures in the foot along with the cuneiform fracture (such as a metatarsal fracture or navicular fracture), he/she may choose to order a Computed Tomography Test (CT Scan). 

A CT scan will provide detailed images of the bones as well as the joint surfaces.  

To learn more about how to diagnose cuneiform fractures, read this supplemental post.

surgery instruments

How Are Cuneiform Fractures Treated?

Nondisplaced Cuneiform Fractures

If you have a nondisplaced cuneiform fracture (fracture is broken but in proper alignment), you should remain non-weight bearing in a cast boot/cast for 6-8 weeks to allow the bone to heal. 

This would be followed by 4 weeks of gradual weight bearing and physical therapy. 

Bone healing may be delayed if you smoke or have certain medical conditions like diabetes. 

Full recovery after a nondisplaced cuneiform fracture could take 3 months. 

Displaced Cuneiform Fractures

If you have a displaced cuneiform fracture (the bone is broken and the fracture fragments are shifted) your doctor will suggest surgery to repair this. 

Oftentimes, displaced cuneiform fractures may extend into the joint spaces (intra-articular fractures). In this case, your doctor may choose to repair the fracture by fusing the midfoot. This will help secure the fracture, reduce pain, and improve stability in the midfoot.  

Surgery would be done under anesthesia in the operating room. Your surgeon will use plates and screws to repair the fracture. You will have to remain off of your foot in a cast/splint for 6-8 weeks after the surgery, with gradual weight bearing in a cast boot for 4 weeks. 

After your fracture is healed, your doctor will recommend physical therapy. Physical therapy can help reduce pain and improve strength/range of motion.  Physical therapy will need to be completed 3 times a week for 1 month. 
Full recovery after surgery for a cuneiform fracture will take 3 months or longer. 

Complications 

Like with any foot surgery, complications can happen. Some of the complications that can occur after cuneiform fracture surgery include: 

  • Persisting pain: Patients may experience pain in the surgical foot long after the surgery, due to the disruption of the surrounding soft tissue, the formation of scar tissue, the presence of hardware, and/or any associated nerve damage.
  • Swelling in the foot for up to a year or more: Due to the inflammation and trauma of the fracture site, swelling of the foot may persist for up to one year or longer. Elevating the limb can help reduce swelling. 
  • Nonunion or malunion of the fusion site: If the fracture does not heal properly, the fusion site may not properly unite (nonunion) or may heal in an incorrect position (malunion), resulting in pain, instability, and/or decreased range of motion. If this is the case, your doctor will suggest using a bone stimulator or surgery. 
  • Painful hardware: If metal hardware is used to stabilize the fracture, the patient may experience pain when the hardware rubs against surrounding tissue, bones, or nerves. In some cases, hardware may need to be removed. 
  • Numbness/Tingling in the foot: Depending on the extent of the trauma, the surgery may cause damage to the nerves in the foot, resulting in a sensation of numbness or tingling. Symptoms can be managed using pain medication and nerve blocks in the foot. 
  • Infection: There is a risk of infection at the site of the fracture, which may delay healing and cause pain and swelling. Your doctor will prescribe antibiotics to clear the infection. 
  • Metal allergy: If metal hardware is used to stabilize the fracture, the patient may develop an allergic reaction to the metal, resulting in redness, swelling, and/or itching in the affected area. In this case, hardware may need to be removed.

Conclusion

Although rare, cuneiform fractures can cause chronic pain and disability.

Long-term complications from undiagnosed cuneiform fractures include arthritis, chronic pain, and abnormalities with walking.

It’s important to seek help from your foot doctor if you suspect you have a cuneiform fracture. 

Prompt diagnosis and management is essential to ensure the best possible outcomes and allow you to return into your activities.

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References

  1. Guler F, Baz AB, Turan A, Kose O, Akalin S. Isolated medial cuneiform fractures: report of two cases and review of the literature. Foot Ankle Spec. 2011 Oct;4(5):306-9. https://pubmed.ncbi.nlm.nih.gov/21926363/
  2. Krebs P, Borchers J. A Middle Cuneiform Stress Fracture in an Adolescent Athlete: A Case Report and Literature Review. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2019;12.https://journals.sagepub.com/doi/full/10.1177/1179544119878712
  3. Choi JY, Lee DJ, Ngissah R, Nam BJ, Suh JS. Categorization of single cuneiform fractures and investigation of related injuries: A 10-year retrospective study. Journal of Orthopaedic Surgery. 2019;27(3).https://journals.sagepub.com/doi/full/10.1177/2309499019866394
  4. Eraslan, A., Ozyurek, S., Erol, B., & Ercan, E. (2013). Isolated medial cuneiform fracture: a commonly missed fracture. Case Reports2013, bcr2013010093.https://casereports.bmj.com/content/2013/bcr-2013-010093.short
  5. Akan, B., & Yildirim, T. (2013). Dorsal dislocation of the intermediate cuneiform with a medial cuneiform fracture: a case report and review of the literature. Case Reports in Orthopedics2013.https://www.hindawi.com/journals/crior/2013/238950/
  6. Khan, K. M., Brukner, P. D., & Bradshaw, C. (1993). Stress fracture of the medial cuneiform bone in a runner. Clinical Journal of Sport Medicine3, 262-262. https://static1.squarespace.com/static/5b6c1c1eaa49a1d8f10020ba/t/5c663850e5e5f0eb50414979/1550202963999/08.+Khan+CJSM+1993+Stress_Fracture_of_the_Medial_Cuneiform_Bone_in_a.9.pdf

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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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