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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 147-149

An Isolated Nondisplaced Medial Cuneiform Fracture Following Indirect Trauma: A Rare and Often Missed Injury


Department of Orthopaedics and Trauma, The North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India

Date of Submission02-Jul-2020
Date of Acceptance02-Sep-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Tashi Galen Khonglah
Room No. 3, OPD Complex, The North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong - 793 018, Meghalaya
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_52_20

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  Abstract 


A 42-year-old female presented with the complaint of acute pain on the medial tarsal region of her left foot. Initial radiographs of the injured foot at that time revealed no significant pathology, and the injury was diagnosed as a “midfoot sprain.” A week later, she presented in the orthopedic outpatient department with persistent pain. Advanced imaging showed an isolated nondisplaced medial cuneiform fracture. Being a nondisplaced fracture, she was treated conservatively, and at 4 months of follow-up, she was pain-free and was able to return to her previous level of activity. Isolated injuries, fractures and/or dislocations of one or more of the three cuneiform bones, are rare. Fractures of the cuneiforms account for only 1.7% of all midfoot fractures. Hence, this fracture is extremely rare, and it can be easily missed at initial admission. Therefore, a high index of suspicion for such mid-foot pain is necessary so that these fractures do not go unnoticed. Plain radiographs are incomplete for diagnosing these fractures, and thus, identification may require more advanced imaging such as computed tomography or magnetic resonance imaging. Prompt diagnosis and appropriate treatment of these isolated medial cuneiform fractures usually heal with a favorable outcome.

Keywords: Cuneiform, fracture, indirect trauma, midfoot, tarsal bone


How to cite this article:
Khonglah TG, Raj A, Borgohain B. An Isolated Nondisplaced Medial Cuneiform Fracture Following Indirect Trauma: A Rare and Often Missed Injury. J Orthop Traumatol Rehabil 2020;12:147-9

How to cite this URL:
Khonglah TG, Raj A, Borgohain B. An Isolated Nondisplaced Medial Cuneiform Fracture Following Indirect Trauma: A Rare and Often Missed Injury. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2021 Oct 23];12:147-9. Available from: https://www.jotr.in/text.asp?2020/12/2/147/305086




  Introduction Top


Isolated injuries, fractures and/or dislocations of one or more of the three cuneiform bones, are rare.[1] Fractures of the cuneiforms account for only 1.7% of all midfoot fractures.[2] Hence, isolated medial cuneiform fractures are extremely rare, and it can be easily missed at initial admission, especially in emergency services.[3] These fractures are commonly a part of a complex injury affecting the foot and ankle joint and mostly result from high energy trauma such as a blow to the dorsal mid-foot, excessive eversion of the foot, hyper-plantarflexion and falling with a foot in a plantarflexed and inverted position.[2],[4],[5] In addition to cuneiform fractures caused by direct trauma and stress, to our knowledge, there are only three cases of medial cuneiform fractures caused by indirect trauma that have been reported in the literature.[2],[6] Here, we present a case of an isolated medial cuneiform fracture due to indirect trauma.


  Case Report Top


A 42-year-old female attended our emergency with the complaint of acute pain on her left foot, which occurred while she was tending her kitchen garden. She recollected that this pain occurred abruptly while walking on the furrowed ground of her garden, following which she was unable to bear weight. On initial clinical examination of her foot, there was mild swelling and tenderness over the dorsum of her midfoot. Ecchymosis and bruising of the plantar and dorsal tarsal areas were absent. The range of motion of her foot and ankle were restricted terminally. A radiograph of the injured foot in both anteroposterior and oblique views revealed no significant pathology [Figure 1]. The injury was diagnosed as a “midfoot sprain” and was immobilized in a below-knee plaster slab. She was prescribed analgesics and was discharged with the instructions not to bear weight, to keep her injured foot elevated, and to apply an ice pack. A week later, she presented in the orthopedic outpatient department with persistent pain on the injured foot. On re-examination, the swelling had subsided but, tenderness was detected on palpating the medial tarsal region of the foot. A computed tomography (CT) scan was performed to visualize any fracture and to determine whether there was a Lisfranc joint disruption. The examination in the coronal view of the CT revealed an isolated nondisplaced linear fracture on the lateral surface of the medial cuneiform [Figure 2]. While in the sagittal view, the CT presented a small break in the cortex of the medial cuneiform [Figure 3]. After discussing the type of fracture with the patient, a short leg cast immobilization was selected with instructions to maintain strict non-weightbearing for 4 weeks. This was then followed by another 4 weeks of progressive weight-bearing in a boot plaster. A gradual return to normal activity with a range of motion exercises was then initiated. By the end of 4 months, the patient was completely pain-free, and she was able to return to her previous level of activity.
Figure 1: Radiographs of the injured foot in anteroposterior and oblique views show no abnormal pathology

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Figure 2: A coronal view of the computed tomography scan shows an isolated nondisplaced linear fracture on the lateral surface of the medial cuneiform (arrow)

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Figure 3: The sagittal view on the computed tomography shows a break in the cortex of the medial cuneiform (arrow)

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  Discussion Top


Both traumatic and nontraumatic fractures of the cuneiforms are uncommon. With fractures of the cuneiforms accounting for only 1.7% of all midfoot fractures, isolated injuries, fractures and/or dislocations, of one or more of the three cuneiform bones are found to be rare. Hence, nondisplaced or minimally displaced cuneiform fractures can be easily overlooked, or the diagnosis can be delayed.[1],[2] The medial, or first cuneiform, has five surfaces – anterior, medial, posterior, lateral, inferior – and a dorsal crest. The lateral surface has a bony eminence on its anteroinferior aspect for the insertion of the strong cuneo-metatarsal-ligament (Lisfranc ligament). On the anterolateral, half of the plantar surface inserts the peroneus longus tendon while the tibialis anterior tendon attaches to the inferior posterior margin of the medial surface.[1] Due to their location in the foot architecture, the cuneiforms are exposed to numerous forces during the gait cycle. The medial cuneiform supports the medial column of the foot between the first metatarsal and the navicular bone, while the lateral cuneiform acts as the “keystone” of the arch with six articulations.[6] Due to the complex nature of the anatomic structures of the bones of the feet, diagnosis of these isolated nondisplaced fractures can be a challenge and maybe easily missed on initial examination.[4] For isolated medial cuneiform injuries, a predominance of direct force transmission has been reported to lead to these subtle fractures. An indirect mechanism of injury was more commonly seen and resulted from violent forefoot abduction, plantar flexion of the forefoot, or from a combination of forces.[1]

In our case, this unusual fracture was due to an indirect injury mechanism, which made the diagnosis more perplexing. The injury, as recalled by the patient, was due to excessive eversion of the foot caused by walking on uneven ground. Radiographs taken immediately after the injury grossly underemphasized the extent of the damage and therefore delayed the diagnosis. The anatomy of the mid-tarsal region is intricate with various articulations, which cause superimposition on direct radiography.[5] Therefore, when radiographs are inconclusive, and suspicion remains high, advanced imaging modalities, including CT and magnetic resonance imaging (MRI) can help in making the correct diagnosis.[2],[7] A diagnosis of “midfoot sprain” in the backdrop of injury to the midfoot with the inability to bear weight should be seen with utmost doubt until further imaging can be obtained to rule out any occult fracture.[2]

Treatment of uncomplicated cuneiform fractures depends on the severity. In patients with minimal displacement, conservative treatment is frequently successful in achieving bony union.[5],[6],[8] As in the present case where the isolated medial cuneiform fracture was nondisplaced and stable, we felt that conservative treatment with a short-leg cast was an appropriate choice for the treatment of this fracture. Nonweight bearing immobilization has been reported to be successful in relieving symptoms and achieving fracture healing in most patients.[7] Complications of this fracture are extremely rare, with only two cases of nonunion reported so far.[9]

This case report highlights a rare injury with a puzzling diagnosis. A high index of suspicion for such mid-foot pain is necessary so that these fractures do not go unnoticed. Prompt diagnosis and appropriate treatment of these isolated medial cuneiform fractures usually heal with favorable outcome. Plain radiographs are incomplete for diagnosing these fractures, and thus, identification may require more advanced imaging such as CT or MRI. As with this case, though the diagnosis was rather delayed, the appropriate treatment in due course of time rendered a positive outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Court-Brown MC, Heckman DJ, McQueen MM, Ricci MW, Tornetta III P. Fractures and dislocations of the midfoot and forefoot. In: Rockwood and Green's Fractures in Adults. 8th ed. Philadelphia, PA: Wolters Kluwer; 2015. p. 2707-14.  Back to cited text no. 1
    
2.
Paisan G, Magister S, Bridgforth A, Yarboro S. Non-traumatic isolated medial cuneiform fracture: A unique mechanism of a rare injury. SAGE Open Med Case Rep 2017;5:1-3. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5721952/. [Last accessed on 2020 May 25].  Back to cited text no. 2
    
3.
Eraslan A, Ozyurek S, Erol B, Ercan E. Isolated medial cuneiform fracture: A commonly missed fracture. BMJ Case Rep 2013;2013:1-2. Available from: https://www.ncbi.nlm.nih. gov/ pmc/articles/PMC3670069/. [Last accessed on 2020 May 25].  Back to cited text no. 3
    
4.
Alemdar C, Uçar BY, Yıldırım A, Kapukaya A. Nonunion of the medial cuneiform: A rare case. Case Rep Med 2013;2013:1-2.  Back to cited text no. 4
    
5.
Guler F, Baz AB, Turan A, Kose O, Akalin S. Isolated medial cuneiform fractures: Report of two cases and review of the literature. Foot Ankle Spec 2011;4:306-9.  Back to cited text no. 5
    
6.
Krebs P, Borchers J. Middle cuneiform stress fracture in an adolescent athlete: A case report and literature review. Clin Med Insights Arthritis Musculoskelet Disord 2019;12:1-4. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785917/. [Last accessed on 2020 May 25].  Back to cited text no. 6
    
7.
Babu NS, Gambardella GV, Bowlby MA. Isolated fracture of the medial cuneiformA case report. J Am Podiatr Med Assoc 2017;107:436-9.  Back to cited text no. 7
    
8.
Taylor SF, Heidenreich D. Isolated medial cuneiform fracture: A special forces soldier with a rare injury. South Med J 2008;101:848-9.  Back to cited text no. 8
    
9.
Tai DH-Y. Isolated medial cuneiform fracture: A case report and review of the literature. Emerg Trauma Care 2017;2:1-4. Available from: https://www.imedpub.com/abstract/isolated-medial-cuneiform-fracture-a-case-report-and-review-of-the-literature-19731.html. [Last accessed on 2020 May 25].  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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