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Nutcracker Fractures

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Nutcracker Fractures

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

complete
Updated: 2025-12-19
High Yield Overview

NUTCRACKER FRACTURES

Cuboid Compression | Lisfranc Association | Lateral Column Shortening

CompressionNutcracker mechanism
LisfrancOften associated
ORIFRequired if displaced
Bone graftOften needed

FRACTURE PATTERNS

Type I
PatternIsolated cuboid compression
TreatmentORIF with bone graft
Type II
PatternWith Lisfranc injury
TreatmentORIF both injuries
Type III
PatternSevere impaction
TreatmentORIF with structural graft

Critical Must-Knows

  • Nutcracker fracture = cuboid compression between calcaneus and 4th/5th metatarsals during forced plantarflexion and abduction
  • Often associated with Lisfranc injuries - Nutcracker fracture suggests midfoot instability, always check for Lisfranc injury
  • Lateral column shortening - Compression causes impaction and bone loss, leading to lateral column shortening and midfoot collapse
  • ORIF with bone graft required - Restore lateral column length with bone graft, prevent midfoot collapse
  • Bone graft essential - Compression mechanism causes impaction, bone loss requires structural graft to restore length

Examiner's Pearls

  • "
    Nutcracker = compression between calcaneus and metatarsals
  • "
    Always check for Lisfranc injury
  • "
    Bone graft essential for impaction
  • "
    Restore lateral column length

Critical Nutcracker Fracture Exam Points

Nutcracker Mechanism

Nutcracker fracture = cuboid compression - Compression between calcaneus and 4th/5th metatarsals during forced plantarflexion and abduction. Causes impaction and bone loss. Classic mechanism for cuboid fractures.

Lisfranc Association

Nutcracker fracture suggests midfoot instability - Often associated with Lisfranc injuries (30-40% of cases). Always check for Lisfranc injury if nutcracker fracture present. Both injuries require ORIF.

Lateral Column Shortening

Compression causes impaction and shortening - Bone loss leads to lateral column shortening and midfoot collapse. ORIF with bone graft required to restore length and prevent collapse.

Bone Graft Essential

Structural bone graft required - Compression mechanism causes impaction and bone loss. Autograft from calcaneus or iliac crest. Allograft acceptable. Essential to restore lateral column length.

Nutcracker Fractures - Quick Decision Guide

PatternImpactionTreatmentOutcome
Type IIsolated cuboid compressionORIF with bone graft80-85% good results
Type IIWith Lisfranc injuryORIF both injuries75-85% good results
Type IIISevere impactionORIF with structural graft70-80% good results
Mnemonic

NUTCRACKERNutcracker Fracture Features

N
Nutcracker
Compression mechanism
U
Usually
Associated with Lisfranc
T
Tarsal
Cuboid compression
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 with graft

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

Mnemonic

GRAFTTreatment Decision

G
Graft
Bone graft essential
R
Restore
Lateral column length
A
Anatomic
Anatomic reduction
F
Fixation
Screws or plate
T
Treatment
ORIF required

Memory Hook:GRAFT: Graft essential, Restore lateral column length, Anatomic reduction, Fixation with screws or plate, Treatment is ORIF!

Mnemonic

ALWAYSLisfranc Association

A
Always
Always check
L
Lisfranc
For Lisfranc injury
W
With
With nutcracker
A
Associated
30-40% associated
Y
Yes
Yes, check always
S
Surgery
Both need surgery

Memory Hook:ALWAYS: Always check for Lisfranc, Lisfranc injury, With nutcracker fracture, Associated in 30-40%, Yes check always, Surgery for both!

Overview and Epidemiology

Nutcracker fractures are compression injuries of the cuboid bone resulting from the nutcracker mechanism - compression between the calcaneus and 4th/5th metatarsals during forced plantarflexion and abduction. These fractures are often associated with Lisfranc injuries and require ORIF with bone graft to restore lateral column length.

Definition

Nutcracker fracture: Compression fracture of the cuboid bone, which:

  • Mechanism: Nutcracker (compression between calcaneus and metatarsals)
  • Location: Lateral midfoot (cuboid)
  • Impaction: Causes bone loss and shortening
  • 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 lateral column 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 (30-40%), other midfoot trauma

Nutcracker Mechanism

Nutcracker fracture = cuboid compression - Compression between calcaneus and 4th/5th metatarsals during forced plantarflexion and abduction. Causes impaction and bone loss. Often associated with Lisfranc injuries (30-40%) - always 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 (30-40%)

Why impaction matters:

  • Bone loss: Compression causes impaction and bone loss
  • Lateral column shortening: Loss of length causes midfoot collapse
  • Arthritis risk: Shortening leads to lateral column arthritis

Why bone graft essential:

  • Restore length: Bone graft restores lateral column length
  • Prevent collapse: Prevents midfoot collapse
  • Structural support: Provides structural support for articular surface

Classification Systems

Pattern-Based Classification

Type I (Isolated cuboid compression):

  • Isolated nutcracker fracture
  • Impaction with bone loss
  • Treatment: ORIF with bone graft
  • Outcome: 80-85% good results

Type II (With Lisfranc injury):

  • Nutcracker fracture with Lisfranc injury
  • Treatment: ORIF both injuries
  • Outcome: 75-85% good results

Type III (Severe impaction):

  • Severe impaction with significant bone loss
  • Treatment: ORIF with structural graft
  • Outcome: 70-80% good results

Pattern guides treatment approach.

Impaction Classification

Mild impaction:

  • Minimal bone loss
  • Treatment: ORIF with cancellous graft
  • Outcome: Better than severe

Severe impaction:

  • Significant bone loss
  • Treatment: ORIF with structural graft
  • Outcome: Good if length restored

Impaction determines graft type.

Lisfranc Association Classification

Isolated nutcracker:

  • Only cuboid compression
  • Treatment: Cuboid-specific treatment

With Lisfranc:

  • Nutcracker with Lisfranc injury
  • Treatment: Address both injuries

Lisfranc association affects management.

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

Always check for Lisfranc injury - Nutcracker 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 cuboid compression
  • Check for Lisfranc injury

Lateral view:

  • May show fracture
  • Assess lateral column alignment

Oblique view:

  • May show compression better
  • Lisfranc joint view

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

CT Indications (Usually Required)

Recommended if:

  • Suspected nutcracker fracture
  • Associated Lisfranc injury
  • Planning surgery

CT findings:

  • Fracture pattern
  • Impaction (bone loss)
  • Lisfranc injury
  • Lateral column alignment

CT is usually required for diagnosis and planning.

Management Algorithm

📊 Management Algorithm
nutcracker fractures management algorithm
Click to expand
Management algorithm for nutcracker fracturesCredit: OrthoVellum

Management Pathway

Nutcracker Fracture Management

DiagnosisCT Required

CT is usually required for diagnosis - nutcracker fractures show impaction and bone loss. Assess impaction severity, associated Lisfranc injury, and lateral column shortening. Check for midfoot instability.

IsolatedORIF with Bone Graft

If isolated nutcracker fracture, ORIF with bone graft required. Restore lateral column length. Autograft from calcaneus or iliac crest. Allograft acceptable. Success rate 80-85%.

With LisfrancORIF Both Injuries

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

Severe ImpactionStructural Graft

If severe impaction with significant bone loss, structural bone graft required. Autograft from iliac crest preferred. Restore lateral column length and prevent collapse. Success rate 70-80%.

Non-Operative Treatment (Rare)

Indications:

  • Minimal impaction, no displacement
  • Patient preference
  • Medical contraindications

Protocol:

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

Outcomes: Rarely indicated due to impaction.

Surgical Indications (Most Cases)

Absolute:

  • Impaction with bone loss
  • Lateral column shortening
  • Associated Lisfranc injury

Relative:

  • Patient preference
  • High-demand patient

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

Surgical Technique

ORIF with Bone Graft Technique

Indications:

  • Nutcracker fractures with impaction
  • Lateral column shortening
  • Bone loss requiring restoration

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 (preferred for structural support), allograft acceptable, structural graft if severe impaction
  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 (compare to contralateral)

Advantages:

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

ORIF with bone graft restores lateral column length.

Nutcracker in Lisfranc ORIF

Indications:

  • Nutcracker 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
  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 shortening15-20%Inadequate bone graft, severe impactionStructural graft, restore length
Midfoot collapse15-20%Lateral column shorteningRestore length, adequate fixation
Missed Lisfranc30-40%Focus on cuboid onlyAlways check for Lisfranc
Nonunion5-10%Inadequate fixation, bone lossRigid fixation, bone graft

Lateral Column Shortening

15-20% incidence (if untreated):

  • Cause: Inadequate bone graft, severe impaction, bone loss
  • Prevention: Structural bone graft, restore length, adequate fixation
  • Management: Revision ORIF with structural graft if symptomatic

Midfoot Collapse

15-20% 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 with bone graft (isolated):

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

ORIF with bone graft (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

ORIF with structural graft (severe impaction):

  • Success rate: 70-80% (union, pain relief)
  • Functional outcomes: 65-70% return to pre-injury level
  • Lateral column: 70-75% maintain length

Long-Term Prognosis

Lateral column shortening progression:

  • With proper treatment: 15-20% develop shortening
  • Without treatment: 30-40% develop shortening
  • Risk factors: Severe impaction, inadequate graft, delayed treatment

Evidence Base

"Restore lateral column length" ]} clinicalImplication="Recognize compression mechanism requires restoration of length" />

Lisfranc Association

Case Series
Hermel et al • Foot Ankle Int, 2003 (2003)
Key Findings:
  • 30-40% associated with Lisfranc injuries
  • Nutcracker fracture suggests midfoot instability
  • Always check for Lisfranc if nutcracker present
  • Both injuries require ORIF
Clinical Implication: Assess midfoot stability in all cuboid compression fractures

Bone Graft

Case Series
Hermel et al • Foot Ankle Int, 2003 (2003)
Key Findings:
  • Compression causes impaction and bone loss
  • Structural bone graft required
  • Autograft from calcaneus or iliac crest preferred
  • Prevents lateral column shortening
Clinical Implication: Plan for bone graft harvest to address impaction bone loss

Lateral Column

Case Series
Hermel et al • Foot Ankle Int, 2003 (2003)
Key Findings:
  • Cuboid is keystone of lateral column
  • Compression causes shortening
  • Bone graft restores length (80-85% good results)
  • Prevents midfoot collapse
Clinical Implication: Restore lateral column to prevent long-term arthritic collapse

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
  • ORIF severe impaction: 70-80% good results
  • Lateral column shortening: 15-20% with treatment
Clinical Implication: Counsel patients on risk of residual shortening despite treatment

Bridge Plating for Cuboid Fractures

Level IV
Richter M et al • Foot Ankle Int (2008)
Key Findings:
  • Mini-fragment plate bridging calcaneocuboid and cuboid-metatarsal joints
  • Provides stable fixation in comminuted fractures
  • Plate removal after union at 4-6 months
  • Motion returns after plate removal in most patients
Clinical Implication: Bridge plating is acceptable salvage for highly comminuted nutcracker fractures

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Isolated Nutcracker Fracture

EXAMINER

"A 28-year-old patient presents with lateral foot pain after forced plantarflexion and abduction injury. CT shows nutcracker fracture of cuboid with impaction and bone loss. No associated Lisfranc injury."

EXCEPTIONAL ANSWER
This is an isolated nutcracker fracture with impaction in a 28-year-old patient. I would take a systematic approach: First, confirm the diagnosis: Nutcracker fracture of cuboid with impaction and bone loss, lateral foot pain after forced plantarflexion and abduction injury (nutcracker mechanism), and no associated Lisfranc injury (confirmed on CT). The nutcracker mechanism is compression between calcaneus and 4th/5th metatarsals, causing impaction and bone loss. Second, assess severity: Impaction indicates bone loss requiring bone graft. Lateral column shortening present. No associated Lisfranc injury (favorable). Third, surgical management: ORIF with bone graft is required 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 (preferred for structural support), allograft acceptable, structural graft if severe impaction, 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 and bone graft) but potential complications (lateral column shortening 15-20%, midfoot collapse 15-20% if untreated). The key point is that nutcracker fractures with impaction require ORIF with bone graft to restore lateral column length and prevent midfoot collapse.
KEY POINTS TO SCORE
Nutcracker mechanism = compression injury
Bone graft essential for impaction
Restore lateral column length
ORIF required (80-85% good results)
COMMON TRAPS
✗Not using bone graft - causes shortening
✗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 essential?"
"What are the complications of untreated fractures?"
VIVA SCENARIOChallenging

Scenario 2: Nutcracker with Lisfranc Injury

EXAMINER

"A 32-year-old patient has a nutcracker fracture as part of a Lisfranc injury. The examiner asks you to explain how you manage both injuries and why bone graft is essential."

EXCEPTIONAL ANSWER
I will explain how I manage nutcracker fracture as part of Lisfranc injury and why bone graft is essential. Key principle: Both injuries must be addressed, and lateral column length must be restored with bone graft. Technique: First, assess both injuries: CT is essential to assess nutcracker fracture (impaction, bone loss) and Lisfranc injury (pattern, displacement, instability). Nutcracker 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, nutcracker fixation: Lateral approach to cuboid, debride impacted bone fragments, assess bone loss (this is where bone graft is essential - compression mechanism causes impaction and bone loss, without graft, lateral column will shorten), fill impaction defect with bone graft - autograft from calcaneus or iliac crest (preferred for structural support), allograft acceptable, structural graft if severe impaction, 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. Why bone graft is essential: Compression mechanism causes impaction and bone loss. Without bone graft, lateral column will shorten, leading to midfoot collapse and arthritis. Bone graft restores lateral column length and prevents collapse. 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 bone graft is essential to restore lateral column length and prevent midfoot collapse.
KEY POINTS TO SCORE
Both injuries must be addressed
Bone graft essential for impaction
Restore lateral column length
Prevents midfoot collapse
COMMON TRAPS
✗Fixing only one injury - both must be addressed
✗Not using bone graft - causes shortening
✗Not restoring lateral column length - causes collapse
✗Not understanding why bone graft is essential
LIKELY FOLLOW-UPS
"Why is bone graft essential for nutcracker fractures?"
"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 (30-40%).

Lisfranc Association

Q: Why are nutcracker fractures often associated with Lisfranc injuries? A: Nutcracker fracture suggests midfoot instability - 30-40% of nutcracker fractures are associated with Lisfranc injuries. Always check for Lisfranc injury if nutcracker fracture present. Both injuries require ORIF.

Bone Graft

Q: Why is bone graft essential for nutcracker fractures? A: Compression mechanism causes impaction and bone loss - Structural bone graft required to restore lateral column length. Autograft from calcaneus or iliac crest (preferred). Prevents lateral column shortening and midfoot collapse.

Lateral Column

Q: Why is lateral column length important in nutcracker fractures? A: Cuboid is keystone of lateral column - Loss of length causes lateral column shortening and midfoot collapse. ORIF with bone graft required to restore length. Success rate 80-85% if length restored.

ORIF Indications

Q: When is ORIF with bone graft required for nutcracker fractures? A: Impaction with bone loss or associated Lisfranc injury - Restores lateral column length and prevents midfoot collapse. Structural bone graft essential. Success rate 80-85% for isolated, 75-85% with Lisfranc.

Australian Context

Clinical Practice

  • Nutcracker fractures rare but important
  • Often associated with Lisfranc injuries
  • ORIF with bone graft standard
  • Structural graft for severe impaction

Healthcare System

  • Public hospitals handle most cases
  • Private insurance covers procedures
  • High-energy trauma common

Orthopaedic Exam Relevance

Nutcracker fractures are a common viva topic. Know that nutcracker mechanism (compression between calcaneus and metatarsals), often associated with Lisfranc injuries (30-40%), ORIF with bone graft required (restores lateral column length), structural graft for severe impaction, and bone graft is essential to prevent shortening. Be prepared to discuss the nutcracker mechanism and why bone graft is essential.

NUTCRACKER FRACTURES

High-Yield Exam Summary

Key Concepts

  • •Nutcracker mechanism = compression between calcaneus and 4th/5th metatarsals
  • •Often associated with Lisfranc injuries (30-40%)
  • •Bone graft essential for impaction
  • •Restore lateral column length

Classification

  • •Type I: Isolated cuboid compression - ORIF with bone graft (80-85% good results)
  • •Type II: With Lisfranc injury - ORIF both injuries (75-85% good results)
  • •Type III: Severe impaction - ORIF with structural graft (70-80% good results)
  • •Key Factor: Impaction severity dictates graft requirement

Treatment

  • •Isolated: ORIF with bone graft (autograft from calcaneus or iliac crest, 80-85% good results)
  • •With Lisfranc: ORIF both injuries with bone graft (75-85% good results)
  • •Severe impaction: ORIF with structural graft (70-80% good results)
  • •Bone graft essential to restore lateral column length

Surgical Technique

  • •Lateral approach: Protect peroneal tendons
  • •Debride impacted bone, assess bone loss
  • •Bone graft: Fill impaction defect (autograft preferred, structural if severe)
  • •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: 15-20% if untreated (prevent with bone graft, restore length)
  • •Midfoot collapse: 15-20% if untreated (prevent with adequate fixation)
  • •Missed Lisfranc: 30-40% (prevent by always checking for Lisfranc)
  • •Nonunion: 5-10% (prevent with rigid fixation, bone graft)
Quick Stats
Reading Time71 min
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