The Nutcracker Fracture of the Cuboid by Indirect Violence

Compression fracture of the cuboid by indirect violence is not mentioned in many textbooks (3, 5, 6, 9, 10, 11) and is seldom referred to in the voluminous literature of the past two decades (7). An isolated reference to cuboidal fracture appears in a single sentence by Schinz, Baensch, Friedl, and Uehlinger (8). Cases were reported by Benassi (1) in 1940, and by Bianchi (2) in 1931. The 5 cases which we are presenting were observed by us during the past year, possibly because these fractures are more common than is generally realized. Case Reports Case 1: A 45-year-old woman caught the tip of her left shoe on the edge of the curb while stepping up from the street. Her entire weight was brought to bear upon her foot, which was forced into marked plantar flexion. Sudden severe pain was felt in the tarsal region, and the patient could not step on the injured foot. Within a few minutes she was seen by an orthopedic surgeon, Dr. D. T. Jones, who noted marked swelling over the dorsum of the tarsus and marked tenderness over the midtarsal area both laterally and medially. X-ray examination revealed a comminuted, impacted fracture of the cuboid, with widening of the calcaneocuboid joint. In addition, an avulsion fracture of the tuberosity of the navicular was found with slight distraction of a crescentic bony fragment (Fig. 1). Because the cuboid was severely comminuted, a midtarsal fusion was done. After ten weeks there was good bony ankylosis of the joint. The patient then began walking and she has had no residual difficulty or disability. Case II: A 48-year-old housewife caught the toe of her right shoe on the edge of a stair step. Her right foot was forced into excessive plantar flexion. Sudden sharp pain was felt in the tarsal area, and she was unable to step on her right foot. Examination showed marked swelling about the dorsum of the tarsus and sharp tenderness over the cuboid and navicular. X-ray examination of the right foot disclosed a severely comminuted fracture of the cuboid with widening and disruption of the calcaneocuboid joint (Fig. 2). An associated avulsion fracture of the tuberosity of the navicular was also present. These fractures were treated conservatively by immobilization in a plaster cast. The cast was removed after ten weeks, when weight-bearing was begun. The patient still had a painful foot with edema over the dorsum of the tarsal area twenty-four weeks after the conclusion of treatment, but after ten more weeks, all symptoms and signs had disappeared. Case III: A 39-year-old woman put her right foot on the gas pedal instead of on the brake in an attempt to avoid a collision while driving her automobile. When she crashed into a wall, her foot jammed against the floor board, with her toes locked against the foot-dashboard. The weight of her body was transmitted through the foot held in plantar flexion.