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Current Orthopaedics (2005) 19, 231–242

KEYWORDMidfoot fraFracture;Tarsal fracStress frac

0268-0890/$ - sdoi:10.1016/j.c

�Correspondifax: +44 1878 7

E-mail addr(N.K. Makwana(M.R. van Liefla

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TRAUMA

Injuries of the midfoot

Nilesh K. Makwanaa,�, Marck R. van Lieflandb

aWrexham Maelor Hospital, Croesnewydd Road, Wrexham, LL13 7TD, UKbNutkin, Church Lane, Selattyn, SY10 7DN, Shropshire, UK

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ee front matter & 2005uor.2005.05.002

ng author. Tel.: +44 19725391.esses: nilesh.makwana@), mrvanliefland@bigfoond).

Summary Injuries of the midfoot are relatively rare but they can lead tosignificant morbidity if missed. Serious injuries may present in a subtle manner andare often misdiagnosed as a sprain. Small avulsion fractures of the navicular andcuboid may be misdiagnosed as a simple avulsion when in fact they represent a moresevere midfoot injury. A high index of suspicion is required. Good quality X-rays withthree views must be obtained and if suspicion exists further imaging with a bonescan, CT or MRI is necessary. Prompt diagnosis and early treatment will preventlong-term disability and morbidity. Salvage procedures following these injuriesoften involve arthrodesis that limit mobility and frequently lead to an unsatisfactoryoutcome.& 2005 Elsevier Ltd. All rights reserved.

Introduction

Injuries of the midfoot are relatively rare. If theseinjuries are missed, however, they can lead tosignificant morbidity and disability. Early recogni-tion of these injuries and prompt accurate treat-ment may minimise the long-term morbidity.Accurate diagnosis using standard three viewsX-rays and if necessary followed by CT, MRI orbone scans should identify most injuries and aid inthe management. Salvage procedures often includearthrodesis of the affected joints and the resultsof this are rarely good. This review will describe

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the common injuries of the midfoot includingtheir classification, investigations, treatment andoutcome.

Anatomy of the midfoot

The midfoot is a relatively rigid structure incomparison to the hindfoot and forefoot and assuch it provides a stable structure to transmit load.The bones comprising the midfoot include thecuboid, navicular and the three cuneiforms.

The cuboid supports the lateral column and ispositioned between the calcaneum and the base offourth and fifth metatarsals. The calcaneocuboidjoint is saddle shaped. The dorsal surface istraversed by extensor digitorum brevis and per-oneus tertius. Ligaments from the dorsum attach

ed.

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N.K. Makwana, M.R. van Liefland232

widely to the navicular, lateral cuneiform andfourth and fifth metatarsals. On the plantar aspectthe cuboid has a groove for the peroneus longustendon. Ligaments on the plantar surface spread tothe fourth and fifth metatarsals and calcaneum aswell as to the navicular and lateral cuneiform.The cuboid articulates with the navicular and afacet for the navicular bone exists in 45.5–54.5%of feet.1

The navicular (scaphoid) is interposed betweenthe cuneiforms and talus. The joint surface isconcave proximally and convex distally with facetsfor the cuneiforms. Similar to the talus most of itsjoint surface is covered with cartilage. Thecalcaneonavicular, talonavicular and navicular-cu-neiform ligaments attach dorsally. The anterior,tibionavicular, part of the deltoid ligament alsosupports the anteromedial aspect of the joint. Thetibialis posterior tendon inserts into the medialtuberosity. A separate tuberosity from the mainnavicular is known as the naviculare secundarium.

The head of the talus lies in a deep socket oracetabulum pedis formed by the navicular, anteriorcalcaneum, the bifurcate ligament and calcaneo-navicular ligaments. The superomedial calcaneo-navicular ligament originates from thesustentaculum tali and inserts on to the navicular.The articular surface is smooth and fibrocartilagi-nous on the volar aspect. The spring ligament(inferior calcaneonavicular ligament) originatesfrom the coronoid cavity of the calcaneus ante-riorly and inserts into the volar aspect of thenavicular. The bifurcate ligament (ligament ofChopart) is formed by the lateral calcaneonavicularand medial calcaneocuboid ligament.

The blood supply of the navicular is derived froma branch of the dorsalis pedis artery dorsally andfrom a branch of the medial plantar artery volarly.The tuberosity receives branches from an anasto-mosis of these two. A rich anastomosis existsaround the circumference of the navicular and apaucity of vessels supplying the central one-thirdoccurs in adults. Torg et al.2 showed with micro-angiographic studies that the lateral and medialthird were vascular and the central one-thirdavascular. This probably accounts for the increasedrate of non-union and avascular necrosis seenfollowing fracture.

The three cuneiforms are positioned between thenavicular and the first three metatarsals. They forma transverse arch with the cuboid. The medialcuneiform has a plantar-based wedge, whereas theintermediate and lateral cuneiform have a dorsallybased wedge. The middle cuneiform is recessed8mm relative to the medial and 4mm relative tothe lateral cuneiform, which creates the mortise

for the second metatarsal base, rather like a tenonin a tenon joint.

Numerous accessory bones exist around themidfoot and they are thought to be developmentalanomalies. The os tibiale (naviculare secundarium)is located on the posteromedial aspect of thenavicular and incorporated in the tibialis posteriortendon. It is seen in 3–12% of feet and may have afibrous, fibrocartilaginous or bony connection. Theos supranaviculare (Pirie’s bone) is located dorsallyto the talonavicular joint and the os vesalianum liesjust proximal to the fifth metatarsal tuberositybase. The os peroneum lies in the tendon ofperoneus longus under the cuboid. Tendon rupturesoften occur in the region and may be misdiagnosedas an avulsion fracture of the fifth metatarsal orcuboid. Awareness of these accessory bones isimportant to avoid misdiagnosing fractures.

The midfoot joints consist of the Chopart’s jointsi.e. the talonavicular and calcaneocuboid, and thelesser tarsal bones, the navicular, cuboid andcuneiforms.

The cuboid and navicular act as an amphiarthro-sis and move together on the anterior calcaneumand talar head. A longitudinal and transverse axisexist. The longitudinal axis is 15� upwards tohorizontal and 9� medial.3 The movement aroundthis axis is supination and pronation and also helicalwith a screwlike action. The second transverse axisis steeper and oblique with dorsiflexion-abductionor plantarflexion-adduction with the calcaneus andtalus fixed.

With the hindfoot in varus the axis of themidtarsal joints are no longer congruent andmotion in the midfoot is reduced. This allows themidfoot to become a rigid lever arm through whichpropulsion can occur during gait. With hindfootvalgus the axes are parallel and the midfootbecomes flexible. This allows the foot to adapt todifferent surfaces and also allows energy absorp-tion during heel strike, which decreases stresses inthe midfoot joints. The medial column, i.e. thetalonavicular, naviculocuneiform and first andsecond tarsometatarsal joint, is relatively rigidcompared to the lateral column, i.e. calcaneocu-boid, cuboid, fourth and fifth metatarsal joint.Therefore, patients tolerate arthrodesis in themedial column better than in the lateral column.

Midtarsal joint injuries

Injuries of the midtarsal joints are rare andfrequently overlooked. They often occur in youngpatients4 and have important economic conse-quences. In one review high energy road traffic

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Injuries of the midfoot 233

accidents accounted for 72% of these injuries and33% of injuries involved the Chopart and/or Lisfrancjoints.4 Associated fractures occurred in 74% ofcases. However, these injuries can occur with lowenergy force as a simple fall or twist.5,6 Delayed orinadequate treatment can lead to permanentdisability.7 The largest series was that reported byMain and Jowett7 who reviewed 71 midtarsal jointinjuries. In their series a delay in the diagnosis wasseen in 41% of cases. The injuries were classifiedbased on the direction of force and the resultingdisplacement. Five groups were identified andthese form the basis of the current classification:

�

longitudinal, � medial, � lateral, � plantar, � crush injuries.

Longitudinal injuries

These accounted for 41% of injuries. The mechan-ism of injury is a force transmitted along themetatarsals in the plantarflexed foot that leads tocompression of the navicular between the talarhead and cuneiform. The navicular splits and amedial fragment is displaced medially. With moresevere injuries an impaction fracture of the taluscan occur. With less plantarflexion of the foot thenavicular can displace dorsally with impaction ofthe lower pole. Undisplaced fractures are treatedwith a below knee walking cast. Displaced fractureswill require closed or open reduction and internalfixation. In Main and Jewett’s series five out of 15patients with pure longitudinal injuries withoutbony displacement medially had a poor result,compared to two out of 14 when medial displace-ment was present. In addition undisplaced injurieshad a better outcome compared to displaced.

Medial injuries

In 30% of injuries forces from the lateral to medialside of the foot lead to medial injuries. There arethree resulting fracture patterns:

�

fracture sprain, � fracture subluxation/dislocation, � swivel dislocation.

Fracture sprains are caused by an inversion strainand X-rays show a flake fracture of the talus ornavicular medially and a flake fracture of the

calcaneus and cuboid laterally. In a subluxation/dislocation injury the whole foot displaces mediallyat the talonavicular and calcaneocuboid joint. Aswivel dislocation is an unusual injury where thetalonavicular joint is disrupted and the calcaneo-cuboid joint remains intact. The foot does notinvert or evert but rotates, swivelling on theinterosseus talocalcaneal ligament. High falls ac-counted for the majority of cases.

Fracture sprains are stable and can be treated bya short period in a below knee walking cast andthereafter protected with a medial arch supportand a hard soled shoe. They can displace if initiallyleft unprotected. A fracture subluxation/disloca-tion requires prompt reduction either closed oropen. The fracture is stabilised with a K-wire orscrews. K-wires are removed at 6 weeks and non-weight bearing is maintained for a further 6 weeks.If screws are used protection in a below non-weightbearing-knee cast for 6 weeks is followed by partialto full weight bearing in a cast or fracture boot fora further 6 weeks. They are removed at 12 weeks. Amedial arch support is prescribed for 9–12 monthsin both cases.

Lateral injuries

These accounted for 17% of injuries. Again thepatterns include a fracture sprain, fracture sub-luxation/dislocation and a swivel type injury. Infracture sprains an abduction force causes anavulsion of the navicular tuberosity or flake frag-ment medially with an impaction injury on thelateral side (Fig. 1). This fracture pattern has alsobeen termed the nutcracker fracture.8–10 Theseinjuries usually occur following a fall. A lateralsubluxation/dislocation at the talonavicular andcalcaneocuboid joint usually occurs following a highfall or road traffic accident. Treatment is similar tomedial injuries. The outcome is better with sprains.The nutcracker injuries can be treated by restoringthe lateral column length and fusing the calcaneo-cuboid joint or, in younger patients, by bonegrafting and temporary stabilisation of the calca-neocuboid joint.10 Dewar and Evan6 recommendedreattaching the avulsed navicular fragment andfusing the calcaneocuboid joint because of betterresults than achieved with a plaster cast.

Plantar forces

These accounted for only 7% of injuries seen inMann and Jowett’s series. These often follow highenergy injuries like road traffic accidents. Injuries

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Figure 1 A 52-year old woman sustained an abductioninjury to her midfoot, resulting in a lateral fracturesprain. Black arrow—impaction fracture cuboid. Whitearrow—avulsion fracture navicular. Note also the osnaviculare secundarium (os tibiale).

N.K. Makwana, M.R. van Liefland234

can vary from a sprain to fracture subluxation/dislocation and swivel injuries.

Crush injuries

These were the least common injuries seen andaccounted for only 6% of cases. Only crush injurieswere associated with a compound injury. Noconstant pattern of injury is seen and the outcomein Mann and Jowett’s series was only fair in 75% ofcases. Soft tissue injury is common and insuring anadequate soft tissue envelope for the foot becomesa primary goal. The principle of management of theosseous structure is maintaining adequate medialand lateral column length to avoid cavus or planusdeformities, respectively. The aim is to obtain aplantigrade foot and to preserve motion in theChopart joints by using stable internal fixation orarthrodesis to maintain anatomical alignment.11 Ifstable fixation of a comminuted navicular is notpossible, a bridging plate from the talus to the firstmetatarsal can be used and removed at 3 months.Sangeorzan et al.11 used this technique in sevenpatients and all fractures healed without loss ofposition. Compound injuries are treated in astandard fashion with early debridement andfracture stabilisation followed by secondary softtissue closure. Compartment syndromes can occurand should be treated appropriately.

Crush injuries to the midfoot are rare and oftenreported as isolated case reports.12,13 Larger serieshave reported a variety of treatment techniquesincluding lag screw fixation across the navicularfragments.14 Main and Jowett used either open orclosed reduction and plaster cast, debridement orexcision of the bone in four patients, resulting inthree fair and one poor result.

Associated problems

Midfoot injuries are rare and can be easily missed ormisdiagnosed as an ankle sprain.6 A high index ofsuspicion should be maintained and simple avulsionsof the navicular tuberosity should not be consideredin isolation. Howie et al.5 found that of 14 patientswith a navicular tuberosity fracture seven haddamage to the anterior process of the calcaneuswhich may have represented an occult subluxationof the midtarsal joint. All seven patients hadprolonged symptoms and three had persistent butnot disabling pain 3 years after injury.5 Theseinjuries were seen in middle aged women falling ashort distance. Occasionally ecchymoses on bothsides of the foot may be seen and can indicate anoccult injury.6 Good quality X-rays including an AP,lateral and oblique should be obtained and ifnecessary a CT scan should be requested. Promptreduction and immobilisation may prevent long-term disability. High energy injuries may beassociated with compound injuries and compart-ment syndrome and these should be treatedpromptly. A below knee amputation was necessaryin 1.9% of cases in a study by Thermann et al.15 Inthe same study 11.6% of cases required a fasciotomyfor compartment syndrome. The outcome of long-itudinal injuries is correlated with the severity ofinjury and displacement.7 Reduction may improveoutcome but this is not guaranteed as cartilagedamage may already be present at injury. Consider-able impairment was seen at an average follow-upof 9 years in the study reported by Thermann etal.15 In cases where severe joint destruction is seena primary arthrodesis may be indicated. The out-come of lateral injuries is not as good as medialinjures and salvage procedures often include atriple arthrodesis. Main and Jowett demonstratedthat the outcome following these injuries dependson the stability of the medial column.7

Fractures of the navicular

The navicular bone is termed the keystone for thevertical stress on the medial arch.16 Following

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Figure 2 Post-traumatic avascular necrosis and osteoarthritis 2 years after an undiagnosed navicular injury.

Injuries of the midfoot 235

trauma it is essential to restore the anatomy toavoid deformity and later disability. The tenuouscentral blood supply has been described and it ishence more likely to develop avascular necrosis ora non-union compared to other midfoot structures(Fig. 2). The diagnosis of navicular fractures hasbeen described as ‘sometimes obvious, frequentlydifficult and occasionally elusive’.16 Fractures ofthe navicular are rare but more common thanfractures of the cuboid or cuneiforms.17 Pain andtenderness over the navicular region should beinvestigated with AP, lateral and oblique X-rayviews. Normal X-rays with persistent pain warrantfurther investigation with a bone scan, CT scan orMRI to rule out occult fractures. Watson-Jones18

first described these injuries as a fracture of thetuberosity, fracture of the dorsal lip and atransverse or horizontal fracture of the body.DeLee19 classified these into four groups, which iscurrently the adopted classification. These are thecortical avulsion fracture also known as the ‘chip’fracture, tuberosity fracture, fractures of the body,and stress fractures.

Dorsal cortical avulsion fracture

The mechanism is usually a twisting injury withinversion and plantar flexion or eversion of thefoot. The dorsal talonavicular ligaments and cap-sule or the anterior part of deltoid is under tensionleading to an avulsion fracture. These fractures arethe most common and accounted for 47% of

fractures in the largest series reported by Eichen-holtz and Levine16. Giannestras and Sammarco20

noted the association with lateral sprains of theankle. Careful examination will distinguish be-tween the two. An occult injury of the Chopartjoints should be suspected. Treatment of this injuryis conservative with a short period of immobilisa-tion with a simple support bandage. Persistentsymptoms can be treated by excision of thefragment. Large fragments which involve morethan 25% of the joint surface should be treated byORIF to minimise discomfort, reduce the risk ofosteoarthritis and prevent subsequent midtarsalsubluxation.

Tuberosity fracture

These injuries result from twisting with eversion orvalgus of the hindfoot. The tibialis posterior tendonand anterior part of the deltoid ligament are undertension resulting in an avulsion of the naviculartuberosity (Figs. 3 and 4). These injuries may beassociated with a compression injury of the lateralcolumn, which represents a more serious midfootinjury, which requires treatment as outlined above.These fractures should not be confused with anaccessory navicular (os tibiale externum), whichhas a smoother outline. If doubt exists the otherfoot can be X-rayed as accessory ossicles are oftenbilateral. For simple avulsion injuries symptomatictreatment with a supportive bandage is all that isrequired. For severe discomfort a period in a

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Figure 3 Navicular avulsion fracture. Note also accessorynavicular!

N.K. Makwana, M.R. van Liefland236

walking cast may be required. Non-union is oftenasymptomatic but excision of the fragment may beindicated when painful. A large fragment ordiastasis of more than 5mm may be an indicationfor ORIF followed by a non-weight-bearing cast for8 weeks.21

Figure 4 Navicular avulsion fracture treated with ORIFand restoration of joint congruency.

Navicular body fractures

Fractures of the body are rare. They usually resultfrom a direct axial load secondary to a fall or byindirect force. A vertical fracture is thought toresult from forcible plantar flexion and abductionof the midfoot. Main and Jowett considered thesefractures as part of the longitudinal midtarsal jointinjuries. These fractures occur with high energytrauma and may be associated with soft tissueinjury and compartment syndrome. Good qualityX-rays should be obtained including an AP, lateraland oblique and if necessary a CT scan. Pinney andSangeorzan et al.14 classified these fractures intothree types (Fig. 5). In type 1 fractures the fractureline is transverse in the coronal plane with a dorsalfragment that is less than 50% of the body (Fig. 6).AP X-ray may show a normal medial border. Themost common is type 2 when the fracture linepasses from dorsolateral to plantarmedial with themain large fragment being dorsomedial. In type 3fractures there is central or lateral comminutionand there may be disruption of the medial columnof the foot and lateral displacement of the foot(Fig. 7). In addition disruption of the calcaneocu-boid joint may be seen. Sanders and Hansen noted

that with the medial fragment intact the foot maydisplace medially with varus of the hindfoot.22

Non-displaced fractures can be treated by a non-weight-bearing cast for 8–10 weeks until union. Indisplaced fractures closed reduction is unlikely tobe maintained and ORIF is recommended. A dualincision may be necessary using a dorsomedial anddorsolateral approach. Care is taken to protect theneurovascular structures that lie in the first webspace to avoid devascularisation of the remainingbone fragments. An extra-articular distractor mayaid with reduction. Bone graft from the distal orproximal tibia may be necessary to fill any defects.Type 1 fractures can be treated using a 3.5 or 4mmlag screw perpendicular to the fracture line. In type

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Figure 6 Navicular fracture, Sangeorzan type 1 with dorsal displacement. Treated by ORIF.

Figure 5 Sangeorzan’s classification of navicular fractures. Type 1 with dorsal fragment, type 2 with dorsomedialfragment, type 3 with central comminution.

Injuries of the midfoot 237

2 fractures comminution of the plantarlateralfragment and subluxation of the dorsomedialfragment makes reduction difficult. An external

distractor such as an external fixator from the talusto the first metatarsal may aid visualisation andreduction. If there is minimal comminution and

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Figure 7 23-year old man with a Sangeorzan type 3navicular fracture, treated by ORIF, obtaining goodrestoration of joint surface.

N.K. Makwana, M.R. van Liefland238

good preservation of the joint surface a lag screwfrom the dorsomedial aspect to the plantarlateralfragment is inserted. If the plantarlateral fragmentis too comminuted then transfixing the dorsomedialfragment to the second or third cuneiforms orcuboid with screws is recommended. If fixation isnot possible, the aim is an ankylosis between thedorsomedial fragment to the cuboid or lateralcuneiform. Persistent subluxation of the talonavi-cular joint is addressed by placing a temporaryK-wire across this joint. In type 3 fractures anattempt should be made to restore normal anatomyif possible and the fragments held by transfixationto the cuneiforms. The outcome following theseinjuries is poor with only one good result out of fourin the series by Pinney et al.14 If significant jointdamage exists then consideration should be givento fuse the navicular cuneiform joints primarily.23

The talonavicular joint should be preserved asfusion limits subtalar movement. The medialcolumn rarely requires a structural iliac bone graftto restore its length. Postoperatively non-weightbearing is advised for 10–12 weeks and K-wires areremoved at 6 weeks. Transfixation screws should beremoved at 6 months to prevent breakage. Amedial arch support should be used for anadditional 6–12 months.

Eichenholtz and Levine16 reviewed the largestseries of 67 navicular fractures of which 19 werebody fractures. Most were managed conservatively.Five patients subsequently required a talonavicularfusion or triple arthrodesis, resulting in oneexcellent, three good and one fair result.16 Pinneyet al.14 reported on their results in 21 navicularfractures. Reduction was satisfactory in all type 1,67% type 2 and 50% of type 3. Of 15 satisfactoryreductions 14 had good results and one fair.Avascular necrosis was seen in two cases and partialavascular necrosis in four. Final outcome wasdetermined by the quality of reduction and by thetype of fracture.

Stress fractures of the navicular

Towne et al.24 first described stress fractures of thenavicular in two boys and noted that they ‘mayrequire special roentgenographic views and lami-nography for detection’. Stress fractures of thenavicular were considered to be rare with anincidence of 0.7% of stress fractures in one series.25

Over 150 cases have been reported and Hunter26

stressed that these injuries were probably morecommon than recognised and this was supported byKhan et al.27 Stress fractures of the navicular aremore common in men than women with an averageage of 20 (range 14–45). Most occur followingsports, particularly track and field events (Fig. 8).An increase in athletic activity in an unfit personwho takes up jogging or in an athlete before animportant event can lead to a sudden increasedstress in the navicular giving rise to a stressfracture. Delay in diagnosis is common with anaverage of 7.2 months in one study.2

Patients usually present with insidious medialfoot pain or a cramp like sensation. Hunter26 notedthat standing on tip toes reproduces pain over thenavicular. There is little swelling but usuallytenderness on palpation. Pain often resolves withrest and most patients can jog but avoid forefootstrike. Failure to recognise these early symptomsand a delayed diagnosis may result in fracturepropagation and displacement.2,26,27 Torg et al.2

found that predisposing features included a short

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Figure 8 17-year old female cross country runner with a navicular stress fracture, treated by ORIF and autologous bonegrafting.

Injuries of the midfoot 239

first metatarsal, metatarsus adductus and hyper-ostosis or stress fractures of the second, third orfourth metatarsal.

If a stress fracture is suspected standing AP,lateral and oblique X-rays should be performed. Itshould be borne in mind that the X-ray features lagsymptoms by 2–3 weeks and serial X-rays may beindicated.28 A coned down view may be necessaryand if X-rays are negative then a bone scan willshow increased uptake. A CT scan will clarify thefracture pattern and whether it is partial orcomplete. The fracture often lies in the centralone-third in the sagittal plane. An MRI scan willshow a characteristic intraosseous band of lowsignal that is continuous with the cortex andsurrounding areas of decreased signal intensity onT1 images. T2 images show high signal changesaround the fracture (Fig. 8).

Stress fractures are treated by non-weight bear-ing for 6–8 weeks. Torg et al.2 treated 10uncomplicated fractures (five partial and fivecomplete non-displaced) by non-weight bearingfor 6–8 weeks and all fractures healed and patientsreturned to full activity by 3.8 months (3–6

months). Fitch et al.29 found that 14 out of 37treated by non-weight bearing in a cast or restresumed sports by 10 months. Khan et al.27 foundthat 86% of cases ð1922Þ resumed sports after treat-ment with non-weight bearing compared to 26% ð 934Þ

treated with weight-bearing. In seven out of ninecases which were treated by weight-bearing rest orwalking cast a delayed or non-union resulted. If astress fracture fails to heal after a period of weightbearing then non-weight bearing is advised for afurther 6–10 weeks with 90% success. Displaced,complete, delayed unions and non-unions should betreated by ORIF and bone grafting followed by non-weight bearing until union. Fitch et al.29 showedthat not all stress fractures heal by non-weightbearing and radiographs may reveal a completefracture, extension of a fracture, delayed unionor a medullary cyst. En bloc resection of thefracture and bone grafting without internal fixationif the fracture was stable was performed resultingin 15 out of 18 cases (80%) becoming asymptomaticand returning to pre-injury sport levels at anaverage of 8 months. CT scanning is usually neededto monitor healing.

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N.K. Makwana, M.R. van Liefland240

New modalities of treatment include externalelectromagnetic or ultrasonic therapy or implan-table electrodes. The long-term efficacy is not yetknown.

Untreated stress fractures may progress to acomplete non-union with subsequent deformity. Atalonavicular or triple arthrodesis with structuralbone grafting can be used as a salvage procedure.

Cuboid fractures

The cuboid is an important bone as it maintains thelateral column of the foot and articulates with boththe calcaneus, fourth and fifth metatarsal and insome cases the navicular. The position of thecuboid is such that isolated fractures of the cuboidare rare. Avulsion of ligament and capsule is themost common cause of cuboid fractures, withfracture dislocation, compression, stress fracture,and toddler’s fractures also seen.28,29 Avulsionfracture and compression ‘nutcracker’ fractureresult from indirect forces which may be associatedwith a midfoot injury.8–10 These injuries need to berecognised and treated as described before. Frac-tures are commonly seen following a road trafficaccident or a fall. Isolated fractures of the cuboidare rare but mal-union is likely to lead to restrictedmovement.30,31

Clinically the patients present following an injurywhich may be a direct force to the lateral border ofthe foot or following a fall with a twisting element.Pain is localised over the cuboid and carefulexamination should exclude a medial Chopartinjury.

Undisplaced fractures can be treated in a belowknee walking cast for 6–8 weeks. The treatment ofdisplaced cuboid fractures is controversial. Hermeland Gerson-Cohen32 recommended that early ar-throdesis in a comminuted fracture would decreasethe period of morbidity. In contrast others haverecommended accurate anatomical reduction andfixation to maintain the lateral column length andmobility.30 Cuboid fractures treated by conserva-tive methods resulted in only fair or poor results inthe series by Main and Jowett7 and all required atriple arthrodesis later. Despite comminution of thejoint articular surface the anatomy can be restoredand if necessary bone graft used with satisfactoryresults obtained.30 The surgical incision shouldspare the stabilising ligaments of the calcaneocu-boid joint and the distal tarsometatarsal ligaments.A small distractor may aid exposure of the joint toassist reduction and a buttress or H-plate applied tomaintain reduction. Occasionally with markedcomminution a plate can extend from the calca-

neus to the fifth metatarsal and allow an ankylosisto form with preservation of lateral column length.Postoperatively the foot is kept non-weight bearinguntil union. The plate is removed at 6 months. Latesymptoms or signs with degenerative changes canbe treated with an arthrodesis.

Stress fractures of the cuboid are rare. Stressfractures in the foot usually involve the navicular(see above), calcaneus and metatarsals. Themechanism of stress fracture of the cuboid is notknown with any certainty as it forms part of thelateral column which is flexible compared to themedial column and therefore protected fromrepetitive stresses. Beaman and Saltzman et al.33

reported on two cases in college athletes who weretreated by immobilisation and activity modifica-tion. This led to the resolution of symptoms in bothcases.

Cuneiform fractures

As with injuries to the cuboid, fractures of thecuneiforms are rare. The mechanism of injury isusually direct trauma and displacement is uncom-mon. Indirect force may result in a cuneiformfracture but these are often associated with aChopart and/or Lisfranc injury and are treated assuch. Isolated fractures of the cuneiform are rare.Patterson34 reported on an isolated fracture of themedial cuneiform following a motorcycle accident.The patient was asymptomatic at 3 months follow-ing anatomical reduction and fixation. Cuneiformfracture-dislocations have been reported and arerelatively uncommon. Closed-reduction of themedial cuneiform may be prevented by interposi-tion of the tibialis anterior tendon and will thenrequire an open reduction.35 Small avulsion injuriescan be treated conservatively in a wooden soleshoe or walking cast. Displaced fractures willrequire good quality X-rays or a CT scan to excludea Chopart or Lisfranc injury. Displaced fractureswill require anatomical reduction and internalfixation followed by a period of non-weight bearingin a plaster cast for 6 weeks (Fig. 9). If associatedligament injury is present then protection for afurther 4–6 weeks is recommended. In comminutedfractures stabilisation with K-wires may be neces-sary and these can be removed at 6 weeks.

Key points

�

Midfoot injuries are rare and often subtle � They often present as small avulsion fractures

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Figure 9 23-year old woman, sustained cuneiform fractures in an RTA. Treated by ORIF and NWB 8 weeks.

Injuries of the midfoot 241

�

A more complex ligamentous injury should besuspected

�

Appropriate treatment can prevent long termdisability

�

Salvage procedures often result in an unsatisfac-tory outcome.

References

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2. Torg JS, Pavlov H, Cooley LH, et al. Stress fractures of thetarsal navicular. J Bone Joint Surg 1982;64A:700–12.

3. Manter JT. Movements of the subtalar and transverse tarsaljoints. Anat Rec 1941;80:407.

4. Richter M, Wippermann B, Krettek C, Schratt H, Hufner T,Thermann H. Fractures and fracture dislocations of themidfoot: occurrence, causes and long term results. FootAnkle Int 2001;22(5):392–8.

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