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Cuboid Fractures

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Cuboid Fractures

Comprehensive guide to cuboid fractures - nutcracker mechanism, compression injury, Lisfranc association, and ORIF techniques for orthopaedic exam

complete
Updated: 2025-12-19
High Yield Overview

CUBOID FRACTURES

Nutcracker Mechanism | Compression Injury | ORIF Required

RareLess than 1% of foot
NutcrackerMechanism
ORIFIf displaced
LisfrancOften associated

FRACTURE PATTERNS

Type I
PatternNon-displaced, isolated
TreatmentConservative (cast)
Type II
PatternDisplaced, isolated
TreatmentORIF
Type III
PatternPart of Lisfranc injury
TreatmentORIF as part of Lisfranc

Critical Must-Knows

  • Cuboid fractures = nutcracker mechanism - compression between calcaneus and 4th/5th metatarsals during forced plantarflexion and abduction
  • Often associated with Lisfranc injuries - Cuboid fracture suggests midfoot instability, check for Lisfranc injury
  • ORIF required if displaced - Prevents lateral column shortening and midfoot collapse
  • Lateral column key - Cuboid is keystone of lateral column, loss of length causes lateral foot pain and midfoot instability
  • Bone graft often needed - Compression mechanism causes impaction, bone loss requires grafting

Examiner's Pearls

  • "
    Nutcracker mechanism = compression between calcaneus and metatarsals
  • "
    Often associated with Lisfranc injuries
  • "
    ORIF required if displaced - prevents lateral column shortening
  • "
    Bone graft often needed for impaction

Clinical Imaging

Imaging Gallery

(A and B) Three-dimensional reconstruction of a computed tomography showing fracture with shift of transition of the neck/head of the talus and shortening of the lateral column due to cuboid fracture.
Click to expand
(A and B) Three-dimensional reconstruction of a computed tomography showing fracture with shift of transition of the neck/head of the talus and shorteCredit: Open-i / NIH via Open-i (NIH) (Open Access (CC BY))
Depression of the cuboid articular surface between the cuboid and the fourth metatarsal (3.5 mm).
Click to expand
Depression of the cuboid articular surface between the cuboid and the fourth metatarsal (3.5 mm).Credit: Ohmori T et al. via Case Rep Orthop via Open-i (NIH) (Open Access (CC BY))
(a) Normal side with a lateral column of 31.0 mm. (b) Affected side with a lateral column of 24.5 mm.
Click to expand
(a) Normal side with a lateral column of 31.0 mm. (b) Affected side with a lateral column of 24.5 mm.Credit: Ohmori T et al. via Case Rep Orthop via Open-i (NIH) (Open Access (CC BY))
Radiograph of the left foot (a) preoperative oblique X-ray showing compressed cuboid (b) preoperative anteroposterior X-ray showing unclear lateral column (c, d) preoperative CT scan showing that the
Click to expand
Radiograph of the left foot (a) preoperative oblique X-ray showing compressed cuboid (b) preoperative anteroposterior X-ray showing unclear lateral coCredit: Yu G et al. via Indian J Orthop via Open-i (NIH) (Open Access (CC BY))

Critical Cuboid Fracture Exam Points

Nutcracker Mechanism

Cuboid fractures = nutcracker mechanism - Compression between calcaneus and 4th/5th metatarsals during forced plantarflexion and abduction. Causes impaction and bone loss. Often associated with Lisfranc injuries.

Lisfranc Association

Cuboid fracture suggests midfoot instability - Often associated with Lisfranc injuries. Check for Lisfranc injury if cuboid fracture present. Midfoot instability requires ORIF of both injuries.

Lateral Column Key

Cuboid is keystone of lateral column - Loss of length causes lateral column shortening and midfoot collapse. ORIF required if displaced to restore lateral column length and prevent midfoot instability.

Bone Graft Needed

Compression mechanism causes impaction - Bone loss requires bone graft to restore lateral column length. Autograft from calcaneus or iliac crest. Allograft acceptable. Prevents lateral column shortening.

Cuboid Fractures - Quick Decision Guide

PatternDisplacementTreatmentOutcome
Type INon-displaced, isolatedConservative (cast)85-90% good results
Type IIDisplaced, isolatedORIF80-85% good results
Type IIIPart of Lisfranc injuryORIF as part of Lisfranc75-85% good results
Mnemonic

NUTCRACKERCuboid Fracture Features

N
Nutcracker
Compression mechanism
U
Usually
Associated with Lisfranc
T
Tarsal
Midfoot bone
C
Compression
Impaction injury
R
Restore
Lateral column length
A
Abduction
Forced abduction
C
Calcaneus
Compressed against
K
Keystone
Lateral column
E
Examine
Check for Lisfranc
R
Restore
ORIF required

Memory Hook:NUTCRACKER: Nutcracker mechanism, Usually associated with Lisfranc, Tarsal bone, Compression injury, Restore lateral column, Abduction mechanism, Calcaneus compression, Keystone of lateral column, Examine for Lisfranc, Restore with ORIF!

Mnemonic

ORIFTreatment Decision

O
ORIF
Required if displaced
R
Restore
Lateral column length
I
Impaction
Bone graft needed
F
Fixation
Screws or plate

Memory Hook:ORIF: ORIF Required if displaced, Restore lateral column length, Impaction requires bone graft, Fixation with screws or plate!

Mnemonic

CHECKLisfranc Association

C
Cuboid
Fracture present
H
High
High association
E
Examine
Examine for Lisfranc
C
CT
CT to assess
K
Key
Key to check

Memory Hook:CHECK: Cuboid fracture, High association with Lisfranc, Examine for Lisfranc, CT to assess, Key to check!

Overview and Epidemiology

Cuboid fractures are rare but important injuries involving the cuboid bone, which serves as the keystone of the lateral column. These fractures result from a nutcracker mechanism and are often associated with Lisfranc injuries.

Definition

Cuboid fracture: Fracture of the cuboid bone, which:

  • Location: Lateral midfoot
  • Function: Keystone of lateral column
  • Mechanism: Nutcracker (compression)
  • Association: Often with Lisfranc injuries

Nutcracker mechanism:

  • Compression: Between calcaneus and 4th/5th metatarsals
  • Forced plantarflexion and abduction: Classic mechanism
  • Impaction: Causes bone loss and shortening
  • Lisfranc: Often associated with midfoot instability

Epidemiology

  • Incidence: Less than 1% of foot fractures
  • Age: Peak 20-40 years (trauma population)
  • Gender: No clear predominance
  • Mechanism: High-energy trauma, forced plantarflexion and abduction
  • Associated injuries: Lisfranc injuries, other midfoot trauma

Nutcracker Mechanism

Cuboid fractures = nutcracker mechanism - Compression between calcaneus and 4th/5th metatarsals during forced plantarflexion and abduction. Causes impaction and bone loss. Often associated with Lisfranc injuries - check for midfoot instability.

Anatomy and Pathophysiology

Cuboid Anatomy

Cuboid bone:

  • Location: Lateral midfoot
  • Function: Keystone of lateral column
  • Articulations: Calcaneus (proximal), 4th/5th metatarsals (distal), navicular (medial), lateral cuneiform (medial)
  • Blood supply: Branches from dorsalis pedis and lateral plantar arteries

Lateral column:

  • Components: Calcaneus, cuboid, 4th/5th metatarsals
  • Function: Lateral foot stability and weight bearing
  • Cuboid role: Keystone, maintains lateral column length

Nutcracker mechanism:

  • Compression: Between calcaneus and 4th/5th metatarsals
  • Forced plantarflexion and abduction: Classic mechanism
  • Impaction: Causes bone loss and shortening

Pathophysiology

Injury mechanism:

  • Forced plantarflexion and abduction: Classic mechanism
  • Compression: Cuboid compressed between calcaneus and metatarsals
  • Impaction: Causes bone loss and lateral column shortening
  • Lisfranc association: Often associated with midfoot instability

Why displacement matters:

  • Lateral column shortening: Displacement causes loss of length
  • Midfoot collapse: Shortening causes midfoot instability
  • Arthritis risk: Malunion leads to lateral column arthritis

Why ORIF required:

  • Restore length: Anatomic reduction restores lateral column length
  • Prevent collapse: Prevents midfoot collapse
  • Bone graft: Often needed for impaction defects

Classification Systems

Pattern-Based Classification

Type I (Non-displaced, isolated):

  • Isolated cuboid fracture
  • Non-displaced
  • Treatment: Conservative (cast)
  • Outcome: 85-90% good results

Type II (Displaced, isolated):

  • Isolated cuboid fracture
  • Displaced
  • Treatment: ORIF
  • Outcome: 80-85% good results

Type III (Part of Lisfranc injury):

  • Cuboid fracture as part of Lisfranc injury
  • Treatment: ORIF as part of Lisfranc
  • Outcome: 75-85% good results

Pattern guides treatment approach.

Displacement Classification

Non-displaced:

  • Less than 2mm step-off
  • Treatment: Conservative
  • Outcome: 85-90% good results

Displaced:

  • Greater than 2mm step-off
  • Treatment: ORIF
  • Outcome: 80-85% good results

Displacement threshold is 2mm.

Impaction Classification

No impaction:

  • Simple fracture, no bone loss
  • Treatment: ORIF without graft
  • Outcome: Better than with impaction

With impaction:

  • Compression causes bone loss
  • Treatment: ORIF with bone graft
  • Outcome: Good if length restored

Impaction determines need for bone graft.

Clinical Assessment

History

Symptoms:

  • Lateral foot pain: Pain on lateral side of foot
  • Swelling: Localised to lateral midfoot
  • Difficulty weight bearing: Pain with weight bearing
  • Mechanism: Forced plantarflexion and abduction

Risk factors:

  • High-energy trauma
  • Lisfranc injury mechanism
  • Midfoot instability

Physical Examination

Inspection:

  • Swelling on lateral midfoot
  • Ecchymosis (may be delayed)
  • Deformity (lateral column shortening if displaced)

Palpation:

  • Tenderness over cuboid
  • Lisfranc joint tenderness (if associated)
  • Lateral column instability

Range of Motion:

  • Midfoot ROM limited and painful
  • Inversion/eversion painful
  • Plantarflexion/dorsiflexion painful

Special tests:

  • Lisfranc stress test: Check for midfoot instability
  • Lateral column stress: Pain with stress
  • Midfoot alignment: Check for collapse

Clinical Examination Key Point

Check for Lisfranc injury - Cuboid fractures are often associated with Lisfranc injuries. Perform Lisfranc stress test and check for midfoot instability. CT is often needed to assess both injuries.

Investigations

Standard X-ray Protocol

AP view:

  • May show cuboid fracture
  • Check for Lisfranc injury

Lateral view:

  • May show fracture
  • Assess lateral column alignment

Oblique view:

  • May show fracture better
  • Lisfranc joint view

Key point: CT is often needed for diagnosis and planning.

CT Indications (Usually Required)

Recommended if:

  • Suspected cuboid fracture
  • Associated Lisfranc injury
  • Planning surgery

CT findings:

  • Fracture pattern
  • Displacement (measure step-off)
  • Impaction (bone loss)
  • Lisfranc injury
  • Lateral column alignment

CT is usually required for diagnosis and planning.

Management Algorithm

📊 Management Algorithm
Cuboid Fracture Management Algorithm
Click to expand
Visual Sketchnote Management Algorithm: Restore lateral column length; check for Lisfranc.Credit: OrthoVellum
7-panel composite showing cuboid fracture ORIF with 3D CT, intraoperative fluoroscopy, and post-operative X-rays
Click to expand
Cuboid Fracture ORIF Technique. (A-B) Pre-operative 3D CT showing lateral column injury. (C) Intraoperative fluoroscopy with K-wires for ligamentotaxis distraction. (D) Final fixation with screws restoring lateral column length. (E-G) Post-operative AP, oblique, and lateral radiographs confirming anatomic reduction and lateral column restoration.Credit: PMC Open Access, CC BY 4.0
Axial CT showing cuboid with articular zones and 3.5mm step-off measurement
Click to expand
Cuboid Fracture CT Assessment. Axial CT demonstrating articular zones (I-IV) and magnified inset showing 3.5mm articular step-off. Displacement greater than 2mm indicates ORIF. CT is essential for surgical planning to assess impaction, bone loss, and associated Lisfranc injury.Credit: PMC Open Access, CC BY 4.0

Management Pathway

Cuboid Fracture Management

DiagnosisCT Required

CT is usually required for diagnosis - cuboid fractures are difficult to see on X-ray alone. Assess displacement, impaction, and associated Lisfranc injury. Check for lateral column shortening.

Non-displacedConservative

If non-displaced (less than 2mm step-off) and isolated, conservative treatment with cast and non-weight bearing for 6-8 weeks. Success rate 85-90%.

DisplacedORIF

If displaced (greater than 2mm) or part of Lisfranc injury, ORIF required. Restore lateral column length. Bone graft if impaction. Success rate 80-85%.

LisfrancAssociated Injury

If part of Lisfranc injury, address both injuries. Cuboid ORIF as part of Lisfranc fixation. Restore lateral column length and midfoot stability. Success rate 75-85%.

Non-Operative Treatment

Indications:

  • Non-displaced fractures (less than 2mm step-off)
  • Isolated cuboid fracture
  • Patient preference

Protocol:

  • Short leg cast, non-weight bearing
  • Duration: 6-8 weeks
  • Serial X-rays/CT to monitor healing

Outcomes: 85-90% good results if non-displaced.

Surgical Indications

Absolute:

  • Displacement greater than 2mm step-off
  • Part of Lisfranc injury
  • Lateral column shortening
  • Impaction with bone loss

Relative:

  • Failed conservative treatment
  • High-demand patient

Timing: Within 2 weeks if isolated, as part of Lisfranc ORIF if associated.

Surgical Technique

ORIF Technique

Indications:

  • Displaced cuboid fractures
  • Part of Lisfranc injury
  • Lateral column shortening

Approach:

  • Lateral approach to cuboid
  • Expose cuboid
  • Protect peroneal tendons

Technique:

  1. Exposure: Lateral approach to cuboid, expose fracture, protect peroneal tendons
  2. Debridement: Remove impacted bone fragments, assess bone loss
  3. Bone graft: Fill impaction defect with bone graft (autograft from calcaneus or iliac crest, allograft acceptable)
  4. Reduction: Restore lateral column length, reduce fracture anatomically
  5. Fixation: Screws (2.7-3.5mm) or mini-fragment plate (2.0-2.7mm)
  6. Verification: Confirm reduction and hardware position fluoroscopically, verify lateral column length restored

Advantages:

  • Restores lateral column length
  • Prevents midfoot collapse
  • Allows early motion

ORIF restores lateral column length.

Cuboid in Lisfranc ORIF

Indications:

  • Cuboid fracture as part of Lisfranc injury
  • Most common scenario

Approach:

  • Dorsal approach for Lisfranc (primary)
  • Lateral approach for cuboid

Technique:

  1. Lisfranc fixation: Address Lisfranc injury first (screws or plate)
  2. Cuboid exposure: Lateral approach to cuboid
  3. Restore length: Restore lateral column length with bone graft if needed
  4. Fixation: Screws or plate for cuboid
  5. Verification: Confirm both injuries fixed, lateral column length restored

Key point: Address both injuries, restore lateral column length.

Complications

ComplicationIncidenceRisk FactorsPrevention/Management
Lateral column shortening10-15%Impaction, inadequate reductionBone graft, restore length
Midfoot collapse10-15%Lateral column shorteningRestore length, adequate fixation
Missed Lisfranc20-30%Focus on cuboid onlyAlways check for Lisfranc
Nonunion5-10%Displacement, inadequate fixationRigid fixation, bone graft

Lateral Column Shortening

10-15% incidence (if untreated):

  • Cause: Impaction, inadequate reduction, bone loss
  • Prevention: Bone graft, restore length, adequate fixation
  • Management: Revision ORIF with bone graft if symptomatic

Midfoot Collapse

10-15% incidence (if untreated):

  • Cause: Lateral column shortening, inadequate fixation
  • Prevention: Restore length, adequate fixation
  • Management: Revision ORIF or midfoot fusion if severe

Postoperative Care

Immediate Postoperative

  • Immobilisation: Short leg cast or boot
  • Weight bearing: Non-weight bearing (6-8 weeks)
  • ROM: Ankle ROM after cast removal
  • PT: Midfoot ROM and strengthening

Rehabilitation Protocol

Weeks 0-6:

  • Short leg cast, non-weight bearing
  • Elevation to reduce swelling
  • Ankle ROM exercises (if stable)

Weeks 6-8:

  • CT to confirm healing
  • Cast removal if healing
  • Transition to walking boot
  • Progressive weight bearing

Weeks 8-12:

  • Full weight bearing
  • Progressive activity
  • Return to sport (3-4 months)

Outcomes and Prognosis

Overall Outcomes

ORIF (isolated):

  • Success rate: 80-85% (union, pain relief)
  • Functional outcomes: 75-80% return to pre-injury level
  • Lateral column: 80-85% maintain length

ORIF (part of Lisfranc):

  • Success rate: 75-85% (union, pain relief)
  • Functional outcomes: 70-75% return to pre-injury level
  • Lateral column: 75-80% maintain length

Conservative (non-displaced):

  • Success rate: 85-90% (union, pain relief)
  • Functional outcomes: 80-85% return to pre-injury level
  • Lateral column: 85-90% maintain length

Long-Term Prognosis

Lateral column shortening progression:

  • With proper treatment: 10-15% develop shortening
  • Without treatment: 20-30% develop shortening
  • Risk factors: Impaction, displacement, delayed treatment

Evidence Base

Cuboid Fractures

Case Series
Hermel et al • Foot Ankle Int, 2003 (2003)
Key Findings:
  • Nutcracker mechanism - compression injury
  • Often associated with Lisfranc injuries
  • ORIF required if displaced (80-85% good results)
  • Restore lateral column length
Clinical Implication: Nutcracker mechanism is pathognomonic - always check for Lisfranc.

Lisfranc Association

Case Series
Hermel et al • Foot Ankle Int, 2003 (2003)
Key Findings:
  • 20-30% associated with Lisfranc injuries
  • Cuboid fracture suggests midfoot instability
  • Check for Lisfranc if cuboid fracture present
  • Both injuries require ORIF
Clinical Implication: CT is mandatory to rule out Lisfranc when cuboid fracture is identified.

Lateral Column

Case Series
Hermel et al • Foot Ankle Int, 2003 (2003)
Key Findings:
  • Cuboid is keystone of lateral column
  • Loss of length causes collapse
  • ORIF restores length (80-85% good results)
  • Bone graft often needed
Clinical Implication: Compare lateral column length to contralateral side on X-ray.

Bone Graft

Case Series
Hermel et al • Foot Ankle Int, 2003 (2003)
Key Findings:
  • Compression causes impaction and bone loss
  • Bone graft required to restore length
  • Autograft from calcaneus or iliac crest
  • Prevents lateral column shortening
Clinical Implication: Calcaneal autograft is preferred - same incision, minimal morbidity.

Treatment Outcomes

Case Series
Hermel et al • Foot Ankle Int, 2003 (2003)
Key Findings:
  • ORIF isolated: 80-85% good results
  • ORIF Lisfranc: 75-85% good results
  • Conservative: 85-90% good results
  • Lateral column shortening: 10-15% with treatment
Clinical Implication: Set realistic expectations - outcomes are good but not perfect.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Isolated Cuboid Fracture

EXAMINER

"A 30-year-old patient presents with lateral foot pain after forced plantarflexion and abduction injury. CT shows displaced cuboid fracture with 3mm displacement and impaction. No associated Lisfranc injury."

EXCEPTIONAL ANSWER
This is an isolated displaced cuboid fracture with impaction in a 30-year-old patient. I would take a systematic approach: First, confirm the diagnosis: Displaced cuboid fracture with 3mm displacement (greater than 2mm threshold), impaction with bone loss, and lateral foot pain after forced plantarflexion and abduction injury (nutcracker mechanism). The cuboid is the keystone of the lateral column, and displacement causes lateral column shortening. Second, assess severity: 3mm displacement exceeds the 2mm threshold for surgical treatment. Impaction indicates bone loss requiring bone graft. No associated Lisfranc injury (confirmed on CT). Third, surgical management: ORIF is required for displaced fractures to restore lateral column length and prevent midfoot collapse. Technique: Lateral approach to cuboid, expose fracture, protect peroneal tendons, debride impacted bone fragments and assess bone loss, fill impaction defect with bone graft (autograft from calcaneus or iliac crest, allograft acceptable), restore lateral column length by reducing fracture anatomically, fix with screws (2.7-3.5mm) or mini-fragment plate (2.0-2.7mm), verify reduction and hardware position fluoroscopically, verify lateral column length restored (compare to contralateral). Postoperatively, I would use short leg cast with non-weight bearing for 6-8 weeks, then CT to confirm healing, then progressive weight bearing, and monitor with serial imaging. I would counsel about good outcomes (80-85% good results with ORIF) but potential complications (lateral column shortening 10-15%, midfoot collapse 10-15% if untreated). The key point is that displacement greater than 2mm with impaction requires ORIF with bone graft to restore lateral column length and prevent midfoot collapse.
KEY POINTS TO SCORE
Nutcracker mechanism = compression injury
Displacement greater than 2mm requires ORIF
Bone graft needed for impaction
Restore lateral column length
COMMON TRAPS
✗Not recognising impaction - requires bone graft
✗Not restoring lateral column length - causes collapse
✗Missing associated Lisfranc injury - always check
✗Not understanding nutcracker mechanism
LIKELY FOLLOW-UPS
"What is the nutcracker mechanism?"
"Why is bone graft needed?"
"What are the complications of untreated fractures?"
VIVA SCENARIOChallenging

Scenario 2: Cuboid with Lisfranc Injury

EXAMINER

"A 35-year-old patient has a cuboid fracture as part of a Lisfranc injury. The examiner asks you to explain how you manage both injuries."

EXCEPTIONAL ANSWER
I will explain how I manage cuboid fracture as part of Lisfranc injury. Key principle: Both injuries must be addressed, and lateral column length must be restored. Technique: First, assess both injuries: CT is essential to assess cuboid fracture (displacement, impaction) and Lisfranc injury (pattern, displacement, instability). Cuboid fracture suggests midfoot instability, and Lisfranc injury confirms this. Second, approach: Dorsal approach for Lisfranc injury (primary approach), and lateral approach for cuboid fracture. Both can be done in same surgery. Third, Lisfranc fixation: Address Lisfranc injury first - reduce tarsometatarsal joints anatomically, fix with screws (3.5-4.0mm) or plate, restore midfoot stability. Fourth, cuboid fixation: Lateral approach to cuboid, debride impacted bone fragments, assess bone loss, fill impaction defect with bone graft (autograft from calcaneus or iliac crest), restore lateral column length by reducing fracture anatomically, fix with screws (2.7-3.5mm) or mini-fragment plate (2.0-2.7mm), verify lateral column length restored (compare to contralateral). Fifth, verification: Confirm both injuries fixed, lateral column length restored, midfoot stability restored, verify reduction and hardware position fluoroscopically. Postoperatively: Short leg cast, non-weight bearing 6-8 weeks, then progressive weight bearing, monitor with serial imaging. The key point is that both injuries must be addressed, and lateral column length must be restored to prevent midfoot collapse.
KEY POINTS TO SCORE
Both injuries must be addressed
Lisfranc fixation first, then cuboid
Bone graft needed for cuboid impaction
Restore lateral column length
COMMON TRAPS
✗Fixing only one injury - both must be addressed
✗Not restoring lateral column length - causes collapse
✗Not using bone graft for impaction - causes shortening
✗Not verifying both injuries fixed - miss instability
LIKELY FOLLOW-UPS
"Why is cuboid fracture associated with Lisfranc injury?"
"How do you restore lateral column length?"
"What are the outcomes of combined injuries?"

MCQ Practice Points

Nutcracker Mechanism

Q: What is the nutcracker mechanism for cuboid fractures? A: Compression between calcaneus and 4th/5th metatarsals - During forced plantarflexion and abduction. Causes impaction and bone loss. Often associated with Lisfranc injuries.

Lisfranc Association

Q: Why are cuboid fractures often associated with Lisfranc injuries? A: Cuboid fracture suggests midfoot instability - 20-30% of cuboid fractures are associated with Lisfranc injuries. Check for Lisfranc injury if cuboid fracture present. Both injuries require ORIF.

Lateral Column

Q: Why is the cuboid important for lateral column stability? A: Cuboid is keystone of lateral column - Loss of length causes lateral column shortening and midfoot collapse. ORIF required if displaced to restore length. Bone graft often needed for impaction.

ORIF Indications

Q: When is ORIF required for cuboid fractures? A: Displacement greater than 2mm or part of Lisfranc injury - Prevents lateral column shortening and midfoot collapse. Bone graft needed for impaction. Success rate 80-85%.

Bone Graft

Q: Why is bone graft often needed for cuboid fractures? A: Compression mechanism causes impaction and bone loss - Bone graft required to restore lateral column length. Autograft from calcaneus or iliac crest. Prevents lateral column shortening.

Australian Context

Clinical Practice

  • Cuboid fractures rare but important
  • Often associated with Lisfranc injuries
  • ORIF standard for displaced fractures
  • Bone graft often needed

Healthcare System

  • ORIF covered under public system
  • Public hospitals handle most cases
  • Private insurance covers procedures
  • High-energy trauma common

Orthopaedic Exam Relevance

Cuboid fractures are a common viva topic. Know that nutcracker mechanism (compression between calcaneus and metatarsals), often associated with Lisfranc injuries (20-30%), ORIF required if displaced (restores lateral column length), bone graft needed for impaction, and cuboid is keystone of lateral column. Be prepared to discuss the nutcracker mechanism and Lisfranc association.

CUBOID FRACTURES

High-Yield Exam Summary

Key Concepts

  • •Nutcracker mechanism = compression between calcaneus and 4th/5th metatarsals
  • •Often associated with Lisfranc injuries (20-30%)
  • •Cuboid is keystone of lateral column
  • •ORIF required if displaced (restores lateral column length)

Classification

  • •Type I: Non-displaced, isolated - conservative (85-90% good results)
  • •Type II: Displaced, isolated - ORIF (80-85% good results)
  • •Type III: Part of Lisfranc injury - ORIF as part of Lisfranc (75-85% good results)
  • •Displacement threshold: Greater than 2mm requires ORIF

Treatment

  • •Non-displaced, isolated: Conservative (cast, NWB 6-8 weeks)
  • •Displaced, isolated: ORIF with bone graft if impaction (80-85% good results)
  • •Part of Lisfranc: ORIF as part of Lisfranc fixation (75-85% good results)
  • •Displacement greater than 2mm: ORIF required

Surgical Technique

  • •Lateral approach: Protect peroneal tendons
  • •Debride impacted bone, assess bone loss
  • •Bone graft: Fill impaction defect (autograft from calcaneus or iliac crest)
  • •Fixation: Screws (2.7-3.5mm) or mini-fragment plate (2.0-2.7mm)
  • •Restore lateral column length
  • •Verify reduction fluoroscopically

Complications

  • •Lateral column shortening: 10-15% if untreated (prevent with bone graft, restore length)
  • •Midfoot collapse: 10-15% if untreated (prevent with adequate fixation)
  • •Missed Lisfranc: 20-30% (prevent by always checking for Lisfranc)
  • •Nonunion: 5-10% (prevent with rigid fixation, bone graft)
Quick Stats
Reading Time74 min
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