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FRACTURE OF THE MEDIAL CUNEIFORM

Rajesh Dharia*, Richard S Moore**, Ian K Ritchie***
*Orthopaedic Registrar; **Medical Student; ***Consultant Surgeon; Dept. of Orthopaedics Stirling Royal Infirmary, Stirling, Scotland.

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After injury if there is swelling with pain except the part is the usual practice for diagnosis. As symptoms and signs did not subside, we resorted to CT scan which revealed the transverse fracture of the medial cuneiform.

INTRODUCTION

This is a report involving a case of an isolated transverse fracture of the medial cuneiform which was ultimately diagnosed by CT scan. It demonstrates the difficulty in detecting this condition using standard radiographs.

CASE REPORT

History

The patient suffered a "dizzy spell" and fell onto her foot. This resulted in nonspecific foot pain and pain on weight bearing. The exact mechanism of injury is not clear.

The patient presented to the accident and emergency 24 hours after the injury.

Examination

Examination on initial presentation in accident and emergency revealed a generally swollen and tender right foot with decreased range of motion.

The initial diagnosis was a soft tissue injury to the foot and a tubigrip support and rest, ice, and elevation was prescribed with eventual mobilisation .

Three weeks later an orthopaedic consultation was arranged because of persisting pain. On examination there was pain over the dorsum of the medial aspect of the midfoot. A plain film X-ray (Fig. 1) demonstrated a small area of sclerosis on the medial cortical area of the medial cuneiform due to an exostosis which had been removed some time ago. A tubigrip support was recommended and a bone scan (Fig. 2) was carried out which revealed a hot spot over the medial cuneiform. Important diagnoses that were considered at this stage included osteomyelitis, vascular tumour deposit or an osteoid osteoma.

Fig 1:	Initial X-ray

 

Fig 2:	Bone scan

A CT scan (Fig. 3) was then carried out which, revealed a transverse fracture of the medial cuneiform in the horizontal plane.

Fig 3:	CT Scan

Management

Management consisted of open reduction and internal fixation. A curved incision was made over the medial aspect of the cuneiform. The fracture surfaces were roughened and held in compression by two 2.7 mm lag screws (Fig. 4). Bone grafting was not necessary. A below knee weight bearing case was applied for six weeks.

The patient was subsequently reviewed 3 months after the surgery and was asymptomatic.

Fig 4:	Same infarct, but at a higher level of scan.

DISCUSSION

Fractures of the cuneiform bones are uncommon. [1] Our search of the literature revealed only one case of an isolated medial cuneiform fracture by direct trauma. [6] This case also demonstrated the limitations of the use of plain film radiographs in the detection of medial cuneiform fracture.

Stress fractures of the cuneiforms are rare with a proposed mechanism of compression due to a large amount of body weight transferred through the medial cuneiform and the base of the first metatarsal. These forces are opposed by strong muscular action. [3,4]

The limitation in using plain film radiography for diagnosis of fractures in this region of the foot is that the standard AP and oblique films are not in the same plane as the fracture. In addition, there are multiple overlapping shadows on the lateral view making fracture detection difficult. [5]

This and the rarity of cuneiform fractures make them difficult to detect by accident and emergency medical staff. It has been found previously that diagnosis of a cuneiform fracture was made on bone scanning and that the sclerosis of the fracture site was only visible on an X-ray after one week[2]

In a patient with a history of injury, with pain and swelling in the foot which doesn’t settle within a month and in the presence of normal standard radiographs, bone scans and CT scans bone may be helpful in finding an occult tarsal fracture.

It is important therefore to have a high index of suspicion when there has been trauma resulting in significant foot oedema and careful evaluation [1] if there is in addition to this, long standing pain and dysfunction.

REFERENCES

1. Bryant MJ, Baird DC St. A case of non-union of the medial cuneiform, Injury. The British Journal of Accident Surgery 1993; 24 : 3.
2. Marymont JH, Mills GQ, Merrit WD. Fracture of the lateral cuneiform bone in the absence of severe direct trauma. The American Journal of Sports Medicine 1980; 8 : 2.
3. Meurman KOA. Less common stress fractures in the foot. British Journal of Radiology 1981; 54 : 1-7.
4. Meurman KOA, Elfving S. Stress fracture of the cuneiform bones. British Journal of Radiology 1980; 53 : 157-60.
5. Schiller MG, Ray DR. Isolated dislocation of the medial cuneiform bone-a rare injury of the tarsus. J Bone Joint Surgery 1970; 52A : 1962.
6. Patterson RH, Petersen D, Cunningham R. Isolated fracture of the medial cuneiform (a case report). Journal of Orthopaedic Trauma 1993; 7 (1) : 94-5.

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