Cuboid and cuneiform fractures

INTRODUCTION — The cuboid acts as a static supporting structure within the lateral column of the foot. The medial, intermediate, and lateral cuneiform bones (sometimes referred to as the first, second, and third cuneiforms, respectively) serve as stabilizing structures within the medial column of the foot. While cuboid and cuneiform fractures are uncommon, they can result in significant short- and long-term pain and dysfunction, particularly if they are missed or mismanaged.

The presentation, diagnosis, and nonoperative management of cuboid fractures will be reviewed here. Other foot injuries and conditions are discussed separately. (See "Overview of foot anatomy and biomechanics and assessment of foot pain in adults" and "Foot and ankle pain in the active child or skeletally immature adolescent: Evaluation" and "Proximal fifth metatarsal fractures" and "Tarsometatarsal (Lisfranc) joint complex injuries" and "Calcaneus fractures".)

EPIDEMIOLOGY — Cuboid fractures are uncommon. According to one retrospective case series, the annual incidence of cuboid fracture is 1.8 injuries per 100,000 population [1]. Epidemiologic studies report mixed findings: some describe a unimodal distribution affecting predominantly young men, while others describe a higher incidence among older women [1,2]. Cuboid fractures are frequently associated with other fractures, dislocations, or ligament injuries and may result in considerable long-term disability. Particularly in high-energy trauma (eg, motor vehicle collision), cuboid fractures may occur in association with several additional tarsal fractures, and complex articular dislocations [3].

Isolated fractures of the cuneiform bones are rare, and even since the development of advanced diagnostic imaging techniques, reports of isolated fractures remain scarce. Thus, there is insufficient epidemiologic data to define the occurrence rate of cuneiform fractures [4]. Based on data from a population of adult industrial workers, the estimated incidence may range from 0.1 to 0.5 percent of all fractures [5]. As with other midfoot fractures, particularly those stemming from high-energy trauma, cuneiform fractures are frequently associated with other tarsal fractures, dislocations, or ligament injuries, which may result in considerable long-term disability. As is the case with other tarsal fractures, subtle cuneiform fractures can easily be missed on radiograph and diagnosis delayed [6,7].

CLINICAL ANATOMY — Foot anatomy is discussed in detail separately. Features of particular relevance to cuboid and cuneiform fractures are described below. (See "Overview of foot anatomy and biomechanics and assessment of foot pain in adults", section on 'Anatomy and biomechanics'.)

The cuboid acts as a keystone within the lateral column of the foot. It articulates with the calcaneus proximally, the tarsal navicular and lateral cuneiform medially, and the fourth and fifth metatarsals distally (figure 1 and figure 2). Multiple ligaments attach along the surfaces of the cuboid (figure 3), creating a static supporting structure within the lateral column.

The tibialis posterior (picture 1) is the only muscle with attachments to the cuboid. The distal tendon of the tibialis posterior has attachments to all midfoot bones and functions as a dynamic stabilizer during the mid-stance phase and toe-off [8]. The peroneal sulcus, a deep groove that runs distally and medially in an oblique fashion on the plantar surface of the foot, houses the peroneus longus tendon. The combination of plantar stabilization from the tibialis posterior and dorsal ligamentous structures allow the cuboid to serve as a static fulcrum for the function of the peroneus longus. Counterbalancing forces resist cuboid subluxation. A stable cuboid maintains the foot in a normal supinated position along the lateral column during the foot strike phase of gait.

The cuboid receives its blood supply from the lateral plantar artery. As a result of local anastomoses, blood supply to the bone is robust and reports of nonunion or osteonecrosis of the cuboid are rare.

The cuneiforms are wedge-shaped bones that contribute to the structure of the medial column of the foot. They articulate with the tarsal navicular proximally, the cuboid laterally, and the first, second, and third metatarsals distally. The medial cuneiform serves as an attachment site for the peroneus longus tendon along the plantar surface and the tibialis anterior tendon along the medial surface. The Lisfranc ligament is a large oblique ligament that extends from the medial cuneiform to the base of the second metatarsal. This ligament provides essential stability to the midfoot as there is no transverse ligament between the first and second metatarsals. The intermediate cuneiform provides attachment sites for multiple ligaments and the tibialis posterior tendon. The lateral cuneiform provides insertion sites for multiple ligaments and the tibialis posterior tendon, while also serving as the origin site for the adductor hallucis and flexor hallucis brevis muscles.

Blood flow to the cuneiform bones is supplied through the dorsal arterial network. This dorsal arterial network provides a robust blood supply and therefore non-union due to blood flow disruption is rare. Specifically, the lateral cuneiform is supplied primarily by the lateral tarsal artery, a branch of the dorsalis pedis. Cadaveric studies demonstrate an extraosseous blood supply to the middle cuneiform consisting of the middle pedicle branch of the dorsalis pedis, while the plantar aspect is supplied by the medial plantar and superficial medial plantar arteries, respectively [9].

The forefoot and midfoot can be divided into five rays, each of which includes a tarsal, metatarsal, and their corresponding phalanges. The first, second, and third rays of the foot are composed of the cuneiforms and the phalanges. As the medial column of the foot requires the first three rays to function as a kinetic chain to generate the force for toe off, any disruption of ligamentous stability or displacement by fracture can impair gait biomechanics.

MECHANISM OF INJURY — Several mechanisms of injury have been described for cuboid fractures. Inversion-type ankle sprains with external rotation of the tibia can produce avulsion fractures of the cuboid. This extreme motion places stress on the distal insertion of the calcaneal-cuboid ligament, producing a small avulsion fracture of the cuboid. This injury may complicate up to 3 to 5 percent of moderate to severe lateral ankle "sprains" [10].

Direct trauma, such as a blow to the dorsolateral foot can cause a crush injury, which is the most severe type of cuboid fracture. A "nutcracker fracture" occurs when an axial load is placed on the heel of a plantarflexed, fixed foot. In this scenario, the cuboid is crushed between the calcaneus and the fourth and fifth metatarsals [11]. Ballet dancers are a special group at risk for a nutcracker type cuboid fracture, due to the stresses placed on the midfoot by the en pointe foot position [12]. Such fractures have also been reported in association with horseback riding injuries [13]. Nutcracker fractures should be suspected following any acute trauma where the cuboid was placed in this vulnerable position. As nutcracker fractures occur via a mechanism similar to that of Lisfranc injuries, concomitant injury to both the cuboid and the Lisfranc joint is more common than an isolated cuboid fracture. (See "Tarsometatarsal (Lisfranc) joint complex injuries".)

Injury patterns for acute cuneiform fractures vary and mechanisms may include direct impact, axial loading of a dorsiflexed or plantarflexed foot, and rotational forces applied to a planted plantarflexed foot [4]. Significant trauma, as may be sustained during motor vehicle accidents or high-impact sports such as American football or rugby, can generate sufficient force to fracture or dislocate multiple cuneiforms. As with cuboid fractures, isolated traumatic fractures of the cuneiform bones are uncommon. Most acute cuboid fractures are combined injuries involving the Lisfranc joint or other surrounding midfoot structures.

Cuboid stress fractures are most commonly seen in ballet athletes and other dancers, but have also been reported in other sports involving large, multi-planar demands on the cuboid, including rugby, running, and gymnastics [14-17]. Stress fractures should be considered in settings consistent with overuse injuries: recent or rapid increases in training regimens leading to a gradual onset and progressive increase in pain at the lateral foot. Information about the assessment and treatment of these injuries comes primarily from a small number of case reports.

Cuneiform stress fractures are rare overall and much less common than other midfoot stress injuries [18]. Based on a few case reports, track and field sprinters may have a greater risk, which may be related to the dramatic stress placed on the medial column of the foot during the initial push-off during maximal sprinting [18]. There may be an association with plantar fasciitis, which also occurs after excessive stress along the medial aspect of the foot [19]. (See "Overview of stress fractures" and "Running injuries of the lower extremities: Risk factors and prevention".)

HISTORY AND EXAMINATION FINDINGS — Patients with acute fractures of the cuboid typically complain of severe pain over the dorsal or dorsolateral foot following trauma. They have difficulty with weight-bearing generally, and particularly walking on their tiptoes. With isolated injury, localized swelling and tenderness is present between the calcaneocuboid (CC) joint and the lateral tarsometatarsal (TMT) joints, but swelling may be more widespread if injuries are more extensive.

Patients with acute fractures of one or more of the cuneiform bones usually present with severe pain over the dorsal or dorsomedial foot. They too have difficulty with weight-bearing and walking on their tiptoes. There is typically localized swelling, ecchymosis, and tenderness somewhere between the Chopart joint and the Lisfranc joint (figure 4).

When a cuboid or cuneiform fracture is suspected, the foot, ankle, and lower leg should be carefully examined, as concomitant injury is common. Correctly diagnosing a small cuboid fracture while missing a subtle tarsometatarsal disruption can lead to poor outcomes. Advanced diagnostic imaging is often required to assess the extent of injury. (See 'Diagnostic imaging' below.)

Palpation of the dorsal and medial foot is important to assess alignment and feel for signs of dislocation or step-off. Passive and active movement involving the midfoot typically elicits focal pain in the presence of either fracture. Particularly with a crush injury, the examiner must be mindful of surrounding soft tissues, which are at risk for compartment syndrome or ischemia [4]. Careful examination and continual reassessment are important. (See "Acute compartment syndrome of the extremities".)

Cuboid stress fractures generally present with the typical progression of stress fracture pain: Initially, pain develops only after a long run or minor trauma, but gradually, it is provoked by lesser amounts of activity until finally, pain occurs at rest. Cuboid stress fractures usually exhibit minimal if any soft tissue swelling and are difficult to detect with bedside ultrasound. Cuneiform stress fractures are exceptionally rare but are reported to present in a similar fashion, albeit with pain most often along the medial column, which can be mistaken for a longitudinal arch strain.

DIAGNOSTIC IMAGING

Plain radiographs, MRI, and approach to imaging — The workup for patients with a possible cuboid or cuneiform fracture begins with weight-bearing radiographs of the foot, including anterior-posterior (AP), lateral, and oblique views (image 1 and image 2). The AP view allows visualization of injuries and deformities best seen in the transverse plane (image 3 and image 4), and provides a view of the medial and lateral columns of the foot [20]. In this view, the lateral border of the medial cuneiform is congruent with the lateral border of the base of the first metatarsal. The medial borders of the second metatarsal base and the intermediate cuneiform are also congruent. The lateral view (image 5) is useful for assessing the calcaneocuboid (CC) joint, in addition to providing an orthogonal perspective to the AP film. The oblique view (image 6) allows for assessment of the articulations between the cuboid and the fourth and fifth metatarsals, as well as the length of the lateral column (image 7). In the oblique film, the medial border of the fourth metatarsal should be colinear with the medial border of the cuboid.

Weight-bearing radiographs should be obtained whenever possible, as subtle but unstable injuries of the midtarsal joint complex (including Lisfranc fracture or dislocation) are often missed on routine, non-weight-bearing radiographs of the foot [4]. Contralateral foot films can be used to aid assessment of alignment, length, and shape of the cuboid. Combination injuries involving the cuboid or cuneiforms and the midtarsal joint complex are much more common than isolated cuboid or cuneiform injury.

In patients with a history of acute trauma and subsequent midfoot pain and tenderness, negative plain radiographs are insufficient to rule out midfoot fracture. In the setting of acute trauma, normal radiographs should be followed by protected weight-bearing, pending the completion of magnetic resonance imaging (MRI) (image 8) or computed tomography (CT). If fracture is suspected, CT imaging with multidimensional reconstruction is preferred (image 9 and image 10). CT allows the clinician to determine fracture patterns, dimensions, degree of comminution, displacement, articular involvement, and associated injuries, and provides information for the surgeon's preoperative planning [4].

In settings of chronic pain or trauma from overuse where the initial plain radiographs are unrevealing, the clinician should have a low threshold for obtaining an MRI (image 11). Cuboid stress fractures are common and often occult [21]. Indeed, as cuboid stress fractures heal relatively rapidly, our clinical experience suggests patients can be nearly asymptomatic by the time they are referred to our specialty clinic. (See "Overview of stress fractures", section on 'Imaging studies'.)

Isolated cuneiform stress injuries are exceptionally rare and likely only occur in cases with other bony anomalies of the foot. However, as with any case of midfoot pain due to overuse in an active athlete, imaging with MRI is indicated for any bony tenderness or discomfort that lingers more than one to two weeks.

Musculoskeletal ultrasound — The appropriate role for ultrasound in the diagnosis of midfoot injuries, including cuboid and cuneiform fractures, is an area of emerging research and has yet to be clearly defined. We use bedside ultrasound to look for conditions that may mimic cuboid or cuneiform fracture. Many such conditions can be ruled out by direct visualization or direct visualization combined with sono-palpation (using ultrasound to asses tenderness at precise locations of potential pathology). Examples of injuries that can be assessed in this manner include fractures at the base of the fifth metatarsal, tarsometatarsal osteoarthritis, enthesopathy of the peroneus brevis, plantar fascia pathology, posterior tibialis tendon rupture, spring ligament rupture, os peroneum pathology, and occult fractures in other bones of the midfoot.

No formal studies of diagnostic ultrasound for the diagnosis of cuboid or cuneiform fractures have been performed. While several case reports describe diagnostic ultrasound being used to identify tarsal bone fractures, positive ultrasonographic findings should be considered preliminary and not definitive for fracture. (See "Evaluation, diagnosis, and select management of common causes of midfoot pain in adults".)

In an observational study of 113 track athletes with foot stress fractures that used MRI as the gold standard, ultrasound was reported to have a sensitivity of 81.8 percent, specificity of 66.6 percent, and overall accuracy of 81.4 percent [22]. While widely cited, this study has limited applicability for the diagnosis of cuboid and cuneiform fractures. First, therapeutic rather than diagnostic ultrasound was used, and increased pain during ultrasound evaluation was counted as a positive finding. Such use of therapeutic ultrasound to diagnose stress fracture is not typical in clinical practice. Second, the number of cuboid fractures was small (4 of 113 total fractures), and no cuneiform fractures were identified.

INDICATIONS FOR SURGICAL REFERRAL — Immediate surgical referral is required for any open fracture or any fractures associated with a significant vascular injury or neurologic deficit. Given the paucity of evidence-based outcome data, further recommendations concerning referral are necessarily based on case reports, case series, and expert opinion [4]. We have organized our referral recommendations around three categories of injury: isolated cuboid fractures; combination cuboid and cuneiform fractures; and, cuboid fractures associated with calcaneal fractures, fifth metatarsal fractures, or Lisfranc injury.

With any isolated cuboid fracture, preservation of normal bony alignment is necessary to avoid long-term pain and dysfunction. Therefore, cuboid fractures that are comminuted or have more than 2 mm of step-off at any articular surface should be referred for possible surgical fixation [23,24]. In the absence of these concerning features, an isolated cuboid fracture can typically be treated nonoperatively and managed by a primary care clinician knowledgeable about fracture management.

Cuboid fractures are frequently associated with additional injuries, and surgical referral is typically necessary in such circumstances. Combined cuneiform and cuboid fractures may be straightforward and amenable to management by primary care, but can be associated with ligamentous injury, which may delay healing. In most cases, injuries involving both the cuboid and a cuneiform are referred to a foot surgeon. Primary care providers with experience managing complex fractures may elect to treat these injuries, but failure to improve with non-operative treatment should prompt surgical referral, as such cases may involve ligamentous or other injury requiring operative management [25]. Failure of conservative management is indicated by the inability to bear weight without pain in a short-leg walking cast after two weeks of limited weight-bearing or the inability to bear weight without pain in a CAM walker boot after six weeks of short-leg walking cast. Any patient who experiences pain with weight-bearing after six weeks of conservative management of a cuboid or cuneiform fracture should be referred to a surgeon for further evaluation.

Cuboid fractures associated with fifth metatarsal or calcaneal fractures, or with a Lisfranc injury, or with other complex midfoot injuries (eg, multiple ligament tears), often require surgical repair [20]. Such injuries are typically associated with high-energy trauma and are difficult to manage, and they should be referred to a foot surgeon.

DIAGNOSIS — Definitive diagnosis of a cuboid or cuneiform fracture may be made with plain radiographs, but some can only be made with advanced imaging studies, although such studies are not necessary in all cases. A cuboid or cuneiform injury should be suspected in any individual complaining of lateral midfoot pain following acute or overuse foot trauma whose examination reveals swelling, tenderness over any of the tarsometatarsal joints, and inability to bear weight or to walk without a limp. Acute fractures of the cuboid and cuneiforms occur from trauma. Typically this involves a direct blow to the lateral foot or a "nutcracker" mechanism, wherein the lateral midfoot is compressed between the calcaneus and metatarsal head while in a plantar flexed position. Acute fractures of the cuboid and cuneiform rarely occur in isolation; they are nearly always accompanied by other midfoot fractures, including high-risk Lisfranc injuries. (See "Tarsometatarsal (Lisfranc) joint complex injuries".)

Cuboid stress fractures are more common than cuneiform stress fractures and typically present with vague, persistent lateral midfoot pain, worsened by prolonged weight-bearing, and possibly by bony tenderness in a running athlete.

Weight-bearing plain radiographs of the foot may reveal signs of injury and establish a presumptive diagnosis. However, magnetic resonance imaging is preferred to make a definitive diagnosis of stress fracture or overuse injury, and computed tomography is preferred to make a definitive diagnosis of acute fracture.

DIFFERENTIAL DIAGNOSIS

Acute, trauma-related cuboid or cuneiform fracture

●Other midfoot fracture ‒ Acute cuboid fractures, cuneiform fractures, and other acute midfoot fractures all typically result from direct trauma or extreme rotational forces (torque) exerted on the midfoot. Either mechanism causes a diffusely swollen, painful midfoot that defies precise assessment of the site of maximum tenderness and precludes many examination maneuvers. A "nutcracker" mechanism involving longitudinal compression of the cuboid can cause a cuboid fracture but is also commonly associated with tarsometatarsal (Lisfranc) injury. Indeed, injuries to the tarsometatarsal joint or other surrounding structures often occur concomitantly with acute cuneiform or cuboid fractures. Fracture of the navicular or an accessory navicular can mimic a cuneiform injury. Definitive diagnosis when necessary generally requires advanced diagnostic imaging, most often with CT. (See 'Diagnostic imaging' above and "Tarsometatarsal (Lisfranc) joint complex injuries".)

●Proximal fifth metatarsal injury ‒ An acute proximal fifth metatarsal injury can be confused with a cuboid fracture, as examination findings may overlap. However, proximal fifth metatarsal injuries can reliably be demonstrated on three-view, weight-bearing radiographs. Since concomitant injury to the fifth metatarsal and a cuneiform or the cuboid is rare, the presence of a fifth metatarsal fracture on radiographs should guide the physician down that treatment pathway. (See "Proximal fifth metatarsal fractures".)

●Plantar calcaneonavicular (spring) ligament rupture ‒ Acute rupture of the spring ligament causes swelling and pain around the calcaneal navicular articulation, typically more medial than a cuneiform or cuboid fracture. However, swelling and pain can sometimes be extensive enough to be mistaken for cuneiform injury. Spring ligament rupture can cause a loss of height in the longitudinal foot arch. Imaging with MRI reveals the ligament injury and absence of fracture. (See "Evaluation, diagnosis, and select management of common causes of midfoot pain in adults", section on 'Medial arch (navicular) injury'.)

Chronic or subacute, overuse injuries of the cuboid and cuneiforms — The conditions that most closely mimic cuboid (and cuneiform) stress fracture include enthesopathy of the peroneus brevis tendon, cuboid subluxation syndrome, and painful os peroneum syndrome.

●Enthesopathy of peroneus brevis ‒ Enthesopathy of the peroneus brevis insertion at the base of the fifth metatarsal can mimic the pain of a cuboid stress fracture. Tenderness and focal pain with resisted foot eversion at the tendon insertion site on the fifth metatarsal styloid can help to distinguish enthesopathy from cuboid stress fracture. When necessary, definitive diagnosis requires imaging with MRI.

●Cuboid subluxation ‒ Cuboid subluxation or cuboid syndrome (the terms are used synonymously) is a poorly understood clinical diagnosis that may present as subacute lateral midfoot pain in athletes. The condition typically presents similar to a lateral foot ligament sprain, with pain and tenderness localized to the cuboid and its calcaneal articulations proximally, and the fourth and fifth metatarsals distally, and is relatively common in dancers. Patients may describe minor foot trauma or feeling a small "pop" in the lateral midfoot. The midtarsal adduction test elicits pain. When a definitive diagnosis is necessary, advanced diagnostic imaging (typically MRI) may be required to distinguish a cuboid stress fracture. (See "Non-Achilles ankle tendinopathy", section on 'Differential diagnosis of lateral ankle tendinopathy'.)

●Os peroneum syndrome ‒ The os peroneum is a rounded accessory ossicle found within the substance of the peroneus longus tendon, which forms a sling around the cuboid as it travels to its insertion on the plantar midfoot, and is located just lateral to the cuboid bone. Rarely, pain may develop at the os peroneum that mimics pain caused by a cuboid avulsion fracture or cuboid stress fracture. Symptoms are thought to occur when the os peroneum fractures acutely or when a multi-partate os develops diastasis due to acute or overuse trauma. The inflamed os causes irritation and tendon pain in the peroneus longus. Typically, the condition is relatively easy to distinguish clinically from other sources of lateral foot pain. The os can be seen on routine radiographs or with bedside ultrasonography. The presence of an os with corresponding focal tenderness strongly suggests the diagnosis. Os peroneum is discussed in greater detail separately. (See "Ankle pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Os peroneum'.)

●Tarsometatarsal osteoarthritis ‒ Tarsometatarsal osteoarthritis can mimic the pain caused by a cuboid or cuneiform fracture, particularly a stress fracture. However, tarsometatarsal osteoarthritis usually exhibits the typical diurnal pain pattern of start-up pain in the morning, followed by a pain-free interval, and then increasing pain as activity accumulates during the day. Early stress injuries of the cuboid and cuneiforms are typically painful only at the end of long workouts, while more advanced fractures hurt with any activity. Physical examination often cannot clearly distinguish between these two entities. While plain radiographs may show typical features of osteoarthritis (joint space narrowing, subchondral sclerosis, and even osteophytes), it is possible for patients with TMT degenerative changes to have an occult cuboid or cuneiform stress injury. Hence, advanced imaging (MRI or CT) is often required to make a definitive diagnosis.

●Chronic longitudinal arch strain, as well as partial tears of the plantar fascia, may cause focal pain near the medial cuneiform. In such cases, the tarsal bone should be nontender and advanced imaging, if obtained, will not reveal a fracture. (See "Overview of foot anatomy and biomechanics and assessment of foot pain in adults", section on 'Midfoot clinical conditions'.)

●Posterior tibialis tendon rupture ‒ Ruptures of the posterior tibialis tendon destabilize the midfoot and can cause extensive swelling. This injury most often causes pain along the medial foot and tarsal tunnel, but pain can extend to the area of the cuneiforms. However, the cuneiforms themselves are non-tender. As the posterior tibialis assists in stabilizing the cuboid, pain in the area of cuboid may result and mimic a low-grade stress fracture. Advanced imaging, if obtained, will not reveal a fracture. (See "Overview of foot anatomy and biomechanics and assessment of foot pain in adults", section on 'Rear foot clinical conditions'.)

MANAGEMENT — Cuboid and cuneiform fractures – particularly isolated fractures - are relatively uncommon and no controlled studies have been published that assess or compare the effectiveness of different treatment strategies. Therefore, the treatment recommendations below are based necessarily upon case reports, small case series, and expert opinion. Isolated, uncomplicated cuboid and cuneiform fractures are amenable to treatment by providers skilled in nonoperative fracture management. However, these uncomplicated fractures are rare. Most cuboid and cuneiform fractures occur concomitantly with other fractures, soft tissue injuries (eg, ligaments), or dislocations, and these complex injuries should be referred to a foot surgeon. (See 'Indications for surgical referral' above.)

Acute cuboid fracture — The initial management of an isolated cuboid fracture generally consists of standard care, including the application of ice and a compression dressing to reduce pain and swelling, elevation of the injury above the level of the patient's heart, and immobilization with a posterior splint or bulky dressing. Fractures with less than 2 mm of displacement, no comminution, and without other associated fractures, major soft tissue injuries (eg, ligament tear), or dislocations can be managed with a short-leg walking cast for approximately six weeks. If the patient complains of pain initially despite immobilization of a truly isolated, nondisplaced fracture, then partial weight-bearing with crutches is permitted for the first two weeks. Nondisplaced, isolated fractures of the cuboid should tolerate full weight-bearing in a well-molded short-leg walking cast after two weeks. Failure to achieve this should prompt the clinician to re-examine the patient and to obtain advanced diagnostic imaging, if not already performed. (See 'Diagnostic imaging' above.)

Following six weeks of immobilization, the cast is removed and patients are placed in a supportive shoe with a rigid longitudinal arch support for at least six weeks. Repeat radiographs are typically not performed with cuboid fractures as clear images of the cuboid are difficult to obtain and radiographic healing lags well behind clinical healing. Patients may have mild pain and stiffness for a few days in the supportive shoe, but these post-immobilization symptoms should clear quickly. If examination elicits persistent tenderness or the patient is unable to tolerate weight-bearing after six weeks of immobilization, a complete reevaluation, including advanced imaging with MRI or CT scan, is needed to look for more complicated or other occult injuries. It is reasonable to obtain surgical referral if tenderness or pain with weight-bearing are present at six weeks. (See 'Indications for surgical referral' above.)

During the six weeks following immobilization, jogging, jumping, running, and all other high-impact activities are discouraged. Swimming, stationary cycling, and elliptical training are encouraged for maintaining fitness, as is recreational walking for short distances. Running in a pool (aqua-jogging) and anti-gravity (alter-G) treadmill running is permitted for patients who have access to such equipment and qualified instruction. In addition to endurance work, the patient should perform rehabilitative exercises, focusing on regaining motion, strength, and proprioception in the lateral foot and ankle. Following 12 total weeks of treatment (6 weeks short-leg walking cast, plus 6 weeks supportive shoe with rigid arch support), the patient is given a 6 to 12 week progressive walk-to-run (or return to walking) program, tailored to the patient's previous level of fitness and desired level of activity [26].

Cuboid stress fracture — With appropriate management, cuboid stress fractures are among the quickest stress fractures to heal, given the bone's rich blood supply. Initial treatment involves sufficient weight-bearing restrictions to ensure the patient is pain-free. Some clinicians take a conservative approach and make all patients non-weight-bearing with crutches for two weeks. However, some experienced clinicians with compliant patients who have already begun to treat their fracture with limited weight-bearing and activity modification at the time of presentation may choose to allow heel-touch weight-bearing immediately, provided this weight-bearing is pain free. For individuals with excessive motion during inversion or plantar flexion and inversion, the addition of some form of ankle support may be helpful when the patient resumes full weight-bearing.

After the patient is pain free for two weeks, he or she may begin to increase their activity level gradually. Our typical progression (from most to least restricted) is described immediately below. Each bulleted activity description is performed for one to two weeks.

●Non-weight-bearing on crutches

●CAM walker (sometimes with crutches for partial weight-bearing during first week)

●Walking to perform activities of daily living (ADLs) in supportive tennis shoe or longitudinal arched shoe

●Walking to perform ADLs, plus swimming (20- to 30-minute session, three to four times/week)

●Walking to perform ADLs, plus stationary cycling (20- to 30-minute session, three to four times/week), and unlimited swimming permitted on off days

●Walking to perform ADLs, plus elliptical trainer (20- to 30-minute session, three to four times/week), unlimited stationary cycling allowed on off days

●Begin 6 to 12 week walk-to-run program, plus elliptical trainer on off days as tolerated

Some patients may want to increase their activity more quickly. As clinically indicated, these patients may spend only one week in each phase of activity. While some stress fractures require a cautious approach, cuboid stress fractures often tolerate this accelerated approach. At any stage of rehabilitation, if the patient experiences a return of pain or worsening discomfort, they should return to a level of activity that causes no pain for one to two weeks, then begin making gradual advances to subsequent stages. Patients with persistent or severe pain should be reassessed by the treating clinician.

Cuneiform fracture — Initial management of an isolated cuneiform fracture generally consists of standard care, including the application of ice and a compression dressing to reduce pain and swelling, elevation of the injury above the level of the patient's heart, and immobilization with a posterior splint or bulky dressing. Fractures with less than 2 mm of displacement, no comminution, and without other associated fractures, major soft tissue injuries (eg, ligament tear), or dislocations are classically managed with a short-leg walking cast for approximately six to eight weeks [4,26]. Practically, we have found that a CAM walker boot (picture 2), with the possible addition of an arch support and arch strapping, works equally well.

After cast or CAM walker immobilization for 6 weeks, patients with uncomplicated cuneiform fractures undergo the same rehabilitative progression as outlined for uncomplicated cuboid fractures above [26]. As with cuboid fractures, patients with persistent pain with weight-bearing at six weeks require careful reassessment, including advanced imaging, and possibly surgical referral. (See 'Acute cuboid fracture' above.)

Conservative treatment with a weight-bearing cast boot is generally effective for patients with cuneiform stress fractures until pain and tenderness have resolved. An arch strap may provide additional comfort.

RETURN TO WORK AND SPORT — The time required to return to work or sport following a cuboid or cuneiform fracture varies considerably depending upon the type of fracture, extent of associated injuries, and activities involved. Most individuals with minor, nondisplaced fractures managed nonsurgically return to full activity within two to three months after the initial injury. For patients with severe injuries (eg, extensively comminuted fracture from crush injury), many months may be required. Patients should avoid any activities that pose a risk of reinjury for three to four weeks after immobilization is discontinued, and should not return to sport until they can perform sport-specific activities without significant pain or dysfunction [26]. Those with sedentary jobs should be able to return to work shortly after the initial injury.

COMPLICATIONS AND PROGNOSIS — Uncomplicated, isolated fractures of the cuboid and cuneiform bones have a relatively good prognosis. Patients typically return from these injuries to full function at their previous level of activity, so long as the injuries are promptly diagnosed, adequately treated, and the patient is compliant with the full course of functional rehabilitation. Fractures limited to the cuboid and one or more cuneiforms also generally heal well.

However, most injuries to the cuboid and cuneiforms are not isolated and hence can be quite complicated. These more complex injuries are associated with an uncertain prognosis that is determined largely by the extent of injury. In general, injuries involving the first ray of the foot, including tarsometatarsal injuries, have the worst prognosis, followed by injuries that involve multiple segments of the medial or lateral column (eg, combined calcaneal-cuboid injury, combined cuboid and proximal fifth metatarsal injury). These more complex injuries are associated with chronic foot pain, long-term biomechanical dysfunction, and uncertain return to athletic activities. The treatment of these combined injuries is often surgical, and even if the athlete does return to activity, they are rarely pain free and often retire from sport within a few years due to chronic pain or dysfunction from degenerative, post-traumatic osteoarthritis.

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of acute fracture management".)

●(See "General principles of definitive fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lower extremity (excluding hip) fractures in adults" and "Society guideline links: Acute pain management".)

SUMMARY AND RECOMMENDATIONS

●Cuboid fracture epidemiology and mechanism – Cuboid fractures are uncommon and are often the result of significant foot trauma. Avulsion injuries occur secondary to inversion type ankle sprains, while crush injuries occur secondary to direct trauma. Cuboid fractures are frequently associated with other fractures, dislocations, or ligament injuries. (See 'Epidemiology' above and 'Mechanism of injury' above.)

●Cuneiform fracture epidemiology and mechanism – Isolated cuneiform fractures are rare. Most cuneiform fractures are associated with other fractures, dislocations, or ligament injuries sustained from significant foot trauma. Mechanisms are varied but generally involve major axial or rotational forces, or direct impact. Stress fractures of the cuneiforms can develop from overuse. (See 'Epidemiology' above and 'Mechanism of injury' above.)

●Clinical presentation and examination – Patients with fractures of the cuboid typically present with severe pain over the dorsal or dorsolateral foot. Patients commonly exhibit localized swelling and tenderness, and movement involving the midfoot elicits pain.

Patients with cuneiform fractures present with pain over the dorsal or dorsomedial foot, and typically cannot bear weight without pain, particularly standing or walking on their toes.

With either cuboid or cuneiform fractures, the foot should be examined carefully for evidence of dislocation and care taken to exclude the presence of compartment syndrome or ischemia. (See 'History and examination findings' above and "Acute compartment syndrome of the extremities".)

●Diagnostic imaging – A standard three-view foot series (anterior-posterior, lateral, and oblique) should be obtained if there is suspicion for any midfoot fracture. Weight-bearing films should be obtained whenever possible, as subtle but unstable injuries of the midtarsal joint complex (eg, Lisfranc fracture or dislocation) are often missed on routine, non-weight-bearing radiographs. Contralateral foot films can be used to aid assessment of alignment, length, and shape of the cuboid.

Advanced diagnostic imaging should be obtained if plain radiographs are unrevealing but concern for fracture persists. CT is generally preferred in the setting of acute injury. MRI is preferred when stress fracture is suspected. (See 'Diagnostic imaging' above and "Tarsometatarsal (Lisfranc) joint complex injuries".)

●Indications for surgical referral – Surgical referral is recommended for any fracture with greater than 2 mm of step-off at any articular surface, comminution, or significant associated injuries (eg, fracture, ligament rupture). (See 'Indications for surgical referral' above.)

●Differential diagnosis – A number of midfoot injuries ranging from other midfoot fractures to tarsometatarsal osteoarthritis can present in similar fashion to cuboid and cuneiform fractures. A differential diagnosis is presented in the text. (See 'Differential diagnosis' above.)

●Management – Isolated, uncomplicated cuboid fractures that do not require surgical referral can be managed with a short-leg walking cast for approximately six weeks. Management details are provided in the text. (See 'Acute cuboid fracture' above and 'Cuboid stress fracture' above.)

Isolated, uncomplicated cuneiform fractures that do not require surgical referral can be managed with a short-leg walking cast for approximately six to eight weeks. Management details are provided in the text. (See 'Cuneiform fracture' above.)

●Return to work and sport – Patients with minor, nondisplaced fractures typically return to full activity two to three months after the initial injury. Return to sport should be based on the patient's ability to perform sport-specific activities without significant pain or dysfunction. (See 'Return to work and sport' above.)