CUNEIFORM FRACTURES
Midfoot Trauma | Lisfranc Association | ORIF Required
FRACTURE PATTERNS
Critical Must-Knows
- Cuneiform fractures = midfoot trauma involving medial, intermediate, or lateral cuneiform - often associated with Lisfranc injuries
- Medial cuneiform most common - Often associated with Lisfranc injury, Lisfranc ligament attaches to medial cuneiform
- ORIF required if displaced - Prevents midfoot instability and arthritis
- Lisfranc association - Cuneiform fractures suggest midfoot instability, always check for Lisfranc injury
- Midfoot stability - Cuneiforms are part of midfoot stability, displacement causes instability
Examiner's Pearls
- "Medial cuneiform most common, Lisfranc association
- "Often associated with Lisfranc injuries
- "ORIF required if displaced
- "Check for midfoot instability
Clinical Imaging
Imaging Gallery
Critical Cuneiform Fracture Exam Points
Lisfranc Association
Cuneiform fractures often associated with Lisfranc injuries - Medial cuneiform is attachment site for Lisfranc ligament. Cuneiform fracture suggests midfoot instability. Always check for Lisfranc injury if cuneiform fracture present.
Medial Most Common
Medial cuneiform most common - Often associated with Lisfranc injury. Lisfranc ligament attaches to medial cuneiform. Displacement causes midfoot instability requiring ORIF.
Midfoot Stability
Cuneiforms are part of midfoot stability - Displacement causes midfoot instability and arthritis. ORIF required if displaced to restore stability and prevent collapse.
ORIF Required
Displacement greater than 2mm requires ORIF - Prevents midfoot instability and arthritis. Screw or plate fixation depending on pattern. Success rate 80-85%."
Cuneiform Fractures - Quick Decision Guide
| Bone | Frequency | Treatment | Outcome |
|---|---|---|---|
| Medial | Most common, Lisfranc association | ORIF | 80-85% good results |
| Intermediate | Rare, often with Lisfranc | ORIF | 75-85% good results |
| Lateral | Rare, isolated or with Lisfranc | ORIF | 75-85% good results |
CUNEIFORMCuneiform Fracture Features
Memory Hook:CUNEIFORM: Cuneiform bones, Usually associated with Lisfranc, Navicular articulation, Examine for Lisfranc, Instability risk, Fixation required, ORIF if displaced, Restore stability, Medial most common!
ORIFTreatment Decision
Memory Hook:ORIF: ORIF Required if displaced, Restore midfoot stability, Instability prevention, Fixation with screws or plate!
CHECKLisfranc Association
Memory Hook:CHECK: Cuneiform fracture, High association with Lisfranc, Examine for Lisfranc, CT to assess, Key to check!
Overview and Epidemiology
Cuneiform fractures are rare but important injuries involving the medial, intermediate, or lateral cuneiform bones of the midfoot. These fractures are often associated with Lisfranc injuries and require ORIF if displaced to restore midfoot stability.
Definition
Cuneiform fracture: Fracture of the medial, intermediate, or lateral cuneiform, which:
- Location: Midfoot, between navicular and metatarsals
- Function: Part of midfoot stability
- Association: Often with Lisfranc injuries
- Treatment: ORIF if displaced
Cuneiform bones:
- Medial cuneiform: Most common, Lisfranc ligament attachment
- Intermediate cuneiform: Rare, often with Lisfranc
- Lateral cuneiform: Rare, isolated or with Lisfranc
Epidemiology
- Incidence: Less than 1% of foot fractures
- Age: Peak 20-40 years (trauma population)
- Gender: No clear predominance
- Mechanism: High-energy trauma, midfoot injury
- Associated injuries: Lisfranc injuries (30-40%), other midfoot trauma
Lisfranc Association
Cuneiform fractures often associated with Lisfranc injuries - Medial cuneiform is attachment site for Lisfranc ligament. Cuneiform fracture suggests midfoot instability. Always check for Lisfranc injury if cuneiform fracture present (30-40% association).
Anatomy and Pathophysiology
Cuneiform Anatomy
Cuneiform bones:
- Medial cuneiform: Largest, articulates with navicular, 1st metatarsal, intermediate cuneiform
- Intermediate cuneiform: Smallest, articulates with navicular, 2nd metatarsal, medial and lateral cuneiforms
- Lateral cuneiform: Articulates with navicular, 3rd metatarsal, intermediate cuneiform, cuboid
Midfoot stability:
- Cuneiforms: Part of midfoot stability
- Lisfranc ligament: Attaches to medial cuneiform
- Function: Maintains midfoot alignment
Lisfranc association:
- Medial cuneiform: Lisfranc ligament attachment site
- Midfoot instability: Cuneiform fracture suggests instability
- 30-40% association: With Lisfranc injuries
Pathophysiology
Injury mechanism:
- High-energy trauma: Midfoot injury
- Lisfranc mechanism: Often associated
- Direct trauma: To midfoot
Why displacement matters:
- Midfoot instability: Displacement causes instability
- Arthritis risk: Malunion leads to midfoot arthritis
- Collapse risk: Instability causes midfoot collapse
Why ORIF required:
- Restore stability: Anatomic reduction restores midfoot stability
- Prevent collapse: Prevents midfoot collapse
- Lisfranc: Often requires addressing both injuries
Classification Systems
Bone-Based Classification
Medial cuneiform:
- Most common
- Often with Lisfranc
- Treatment: ORIF
- Outcome: 80-85% good results
Intermediate cuneiform:
- Rare
- Often with Lisfranc
- Treatment: ORIF
- Outcome: 75-85% good results
Lateral cuneiform:
- Rare
- Isolated or with Lisfranc
- Treatment: ORIF
- Outcome: 75-85% good results
Bone type guides treatment approach.
Clinical Assessment
History
Symptoms:
- Midfoot pain: Pain in midfoot
- Swelling: Localised to midfoot
- Difficulty weight bearing: Pain with weight bearing
- Mechanism: High-energy trauma
Risk factors:
- High-energy trauma
- Lisfranc injury mechanism
- Midfoot instability
Physical Examination
Inspection:
- Swelling on midfoot
- Ecchymosis (may be delayed)
- Deformity (midfoot collapse if displaced)
Palpation:
- Tenderness over cuneiforms
- Lisfranc joint tenderness (if associated)
- Midfoot instability
Range of Motion:
- Midfoot ROM limited and painful
- Inversion/eversion painful
Special tests:
- Lisfranc stress test: Check for midfoot instability
- Midfoot stress: Pain with stress
- Midfoot alignment: Check for collapse
Clinical Examination Key Point
Always check for Lisfranc injury - Cuneiform fractures are often associated with Lisfranc injuries (30-40%). 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 cuneiform fracture
- Check for Lisfranc injury
Lateral view:
- May show fracture
- Assess midfoot alignment
Oblique view:
- May show fracture better
- Lisfranc joint view
Key point: CT is often needed for diagnosis and planning.
Management Algorithm
Management Pathway
Cuneiform Fracture Management
CT is usually required for diagnosis - cuneiform fractures are difficult to see on X-ray alone. Assess displacement, associated Lisfranc injury, and midfoot instability. Check for midfoot collapse.
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%.
If displaced (greater than 2mm) or part of Lisfranc injury, ORIF required. Restore midfoot stability. Screw or plate fixation. Success rate 80-85%.
If part of Lisfranc injury, address both injuries. Cuneiform ORIF as part of Lisfranc fixation. Restore midfoot stability. Success rate 75-85%.
Surgical Technique
ORIF Technique
Indications:
- Displaced cuneiform fractures
- Part of Lisfranc injury
- Midfoot instability
Approach:
- Dorsal approach to cuneiform
- Expose cuneiform
- Protect neurovascular structures
Technique:
- Exposure: Dorsal approach to cuneiform, expose fracture, protect neurovascular structures
- Reduction: Anatomic reduction of fracture to restore midfoot stability
- Fixation: Screws (2.7-3.5mm) or mini-fragment plate (2.0-2.7mm)
- Verification: Confirm reduction and hardware position fluoroscopically, verify midfoot stability restored
Advantages:
- Restores midfoot stability
- Prevents collapse
- Allows early motion
ORIF restores midfoot stability.
Complications
| Complication | Incidence | Risk Factors | Prevention/Management |
|---|---|---|---|
| Midfoot instability | 10-15% | Displacement, inadequate reduction | Anatomic reduction, adequate fixation |
| Midfoot collapse | 10-15% | Instability, inadequate fixation | Restore stability, adequate fixation |
| Missed Lisfranc | 30-40% | Focus on cuneiform only | Always check for Lisfranc |
| Nonunion | 5-10% | Displacement, inadequate fixation | Rigid fixation |
Midfoot Instability
10-15% incidence (if untreated):
- Cause: Displacement, inadequate reduction, Lisfranc injury
- Prevention: Anatomic reduction, adequate fixation
- Management: Revision ORIF or midfoot fusion if severe
Midfoot Collapse
10-15% incidence (if untreated):
- Cause: Midfoot instability, inadequate fixation
- Prevention: Restore stability, 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
- Midfoot stability: 80-85% maintain stability
ORIF (part of Lisfranc):
- Success rate: 75-85% (union, pain relief)
- Functional outcomes: 70-75% return to pre-injury level
- Midfoot stability: 75-80% maintain stability
Conservative (non-displaced):
- Success rate: 85-90% (union, pain relief)
- Functional outcomes: 80-85% return to pre-injury level
- Midfoot stability: 85-90% maintain stability
Long-Term Prognosis
Midfoot instability progression:
- With proper treatment: 10-15% develop instability
- Without treatment: 20-30% develop instability
- Risk factors: Displacement, Lisfranc injury, delayed treatment
Evidence Base
Cuneiform Fractures
- Often associated with Lisfranc injuries (30-40%)
- Medial cuneiform most common
- ORIF required if displaced (80-85% good results)
- Restore midfoot stability
Lisfranc Association
- 30-40% associated with Lisfranc injuries
- Medial cuneiform is Lisfranc ligament attachment
- Cuneiform fracture suggests midfoot instability
- Always check for Lisfranc if cuneiform present
Midfoot Stability
- Cuneiforms are part of midfoot stability
- Displacement causes instability
- ORIF restores stability (80-85% good results)
- Prevents midfoot collapse
Treatment Outcomes
- ORIF isolated: 80-85% good results
- ORIF Lisfranc: 75-85% good results
- Conservative: 85-90% good results
- Midfoot instability: 10-15% with treatment
Medial Cuneiform
- Medial cuneiform most common
- Often associated with Lisfranc injury
- Lisfranc ligament attaches to medial cuneiform
- Displacement causes midfoot instability
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Isolated Medial Cuneiform Fracture
"A 30-year-old patient presents with midfoot pain after high-energy trauma. CT shows displaced medial cuneiform fracture with 3mm displacement. No associated Lisfranc injury."
Scenario 2: Cuneiform with Lisfranc Injury
"A 35-year-old patient has a medial cuneiform fracture as part of a Lisfranc injury. The examiner asks you to explain how you manage both injuries."
MCQ Practice Points
Medial Cuneiform
Q: Why is medial cuneiform the most common cuneiform fracture? A: Medial cuneiform is attachment site for Lisfranc ligament - Often associated with Lisfranc injuries (30-40%). Largest cuneiform. Displacement causes midfoot instability requiring ORIF.
Lisfranc Association
Q: Why are cuneiform fractures often associated with Lisfranc injuries? A: Cuneiform fracture suggests midfoot instability - 30-40% of cuneiform fractures are associated with Lisfranc injuries. Medial cuneiform is Lisfranc ligament attachment site. Always check for Lisfranc injury if cuneiform fracture present.
Midfoot Stability
Q: Why is midfoot stability important in cuneiform fractures? A: Cuneiforms are part of midfoot stability - Displacement causes midfoot instability and arthritis. ORIF required if displaced to restore stability. Success rate 80-85% if stability restored.
ORIF Indications
Q: When is ORIF required for cuneiform fractures? A: Displacement greater than 2mm or part of Lisfranc injury - Prevents midfoot instability and collapse. Screw or plate fixation. Success rate 80-85% for isolated, 75-85% with Lisfranc.
Treatment
Q: What is the treatment for cuneiform fractures? A: ORIF if displaced (greater than 2mm) or part of Lisfranc injury - Restores midfoot stability and prevents collapse. Conservative treatment for non-displaced isolated fractures (85-90% good results). Success rate 80-85% with ORIF.
Australian Context
Clinical Practice
- Cuneiform fractures rare but important
- Often associated with Lisfranc injuries
- ORIF standard for displaced fractures
- Midfoot stability critical
Healthcare System
- ORIF covered under public system
- Public hospitals handle most cases
- Private insurance covers procedures
- High-energy trauma common
Orthopaedic Exam Relevance
Cuneiform fractures are a common viva topic. Know that medial cuneiform most common (Lisfranc ligament attachment), often associated with Lisfranc injuries (30-40%), ORIF required if displaced (restores midfoot stability), and always check for Lisfranc injury. Be prepared to discuss the Lisfranc association and midfoot stability.
CUNEIFORM FRACTURES
High-Yield Exam Summary
Key Concepts
- •Medial cuneiform most common (Lisfranc ligament attachment)
- •Often associated with Lisfranc injuries (30-40%)
- •Cuneiforms are part of midfoot stability
- •ORIF required if displaced (restores midfoot stability)
Classification
- •Medial: Most common, Lisfranc association - ORIF (80-85% good results)
- •Intermediate: Rare, often with Lisfranc - ORIF (75-85% good results)
- •Lateral: Rare, isolated or with Lisfranc - ORIF (75-85% good results)
- •Key Factor: Pattern dictates approach and Lisfranc evaluation
Treatment
- •Non-displaced, isolated: Conservative (cast, NWB 6-8 weeks)
- •Displaced, isolated: ORIF (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
- •Dorsal approach: Protect neurovascular structures
- •Reduction: Anatomic reduction to restore midfoot stability
- •Fixation: Screws (2.7-3.5mm) or mini-fragment plate (2.0-2.7mm)
- •Verify midfoot stability restored
- •Verify reduction fluoroscopically
Complications
- •Midfoot instability: 10-15% if untreated (prevent with anatomic reduction)
- •Midfoot collapse: 10-15% if untreated (prevent with adequate fixation)
- •Missed Lisfranc: 30-40% (prevent by always checking for Lisfranc)
- •Nonunion: 5-10% (prevent with rigid fixation)