Cuboid and Nutcracker Fractures

Figure 12.1

AP and lateral injury radiographs of the right tibia and right foot

Figure 12.2

Axial, coronal, and sagittal reformats of the right foot

Figure 12.3

Three-dimensional reformats of the right foot

Treatment and Timing of Surgery

After administration of appropriate prophylactic antibiotics, the patient was taken to the operating room for emergent treatment of his open tibia and fibula fractures. After tibial stabilization, stress radiographs were obtained to further assess the foot injury. First tarsal-metatarsal joint instability was noted along with an avulsion fracture of the base of the second metatarsal (Fig. 12.4). Excessive swelling of the foot was present and therefore it was planned to perform delayed reconstruction of the foot injuries. Postoperatively, the patient was placed into a well-padded posterior splint for soft-tissue immobilization. The patient had significant foot and ankle edema, which precluded surgical intervention at the primary hospital admission. He was discharged to home and then seen in the outpatient office 7 days later to assess edema. Once his edema had resolved and the soft tissues were amenable to surgical dissection, he was electively scheduled for repair of his right-foot injury.

Figure 12.4

Intraoperative stress radiographs

Surgical Tact

Position

Supine on a radiolucent operating table with a rolled sheet bump under the ipsilateral hip and fluoroscopy from the contralateral side of the table. The operative leg had an unsterile tourniquet placed prior to draping and a sterile radiolucent padded triangle was placed behind the knee for optimal positioning of the foot and relaxation of the gastrocnemius soleus (Fig. 12.5). Appropriate antibiotic prophylaxis was delivered within 60 mins of incision and a surgical time-out was performed.

Figure 12.5

Limb position with padded triangular wedge

Approach

Due to combined medial and lateral columnar injuries, a dual-incision approach was utilized. This encompassed a dorsal medial utility incision as well as a lateral incision allowing for surgical visualization of the first and second tarsometatarsal junction, navicular injury, as well as lateral column/cuboid injury.

Fracture Reduction and Fixation (Medial Column)

Reconstruction began with medial column restoration. Direct exposure of the entire medial column provided for anatomical reduction and safe hardware placement. Reconstruction began by addressing the first metatarsal injury. Direct visualization of the joint is mandatory to avoid medial columnar mal-reduction. Retrograde screw fixation from the base of the first metatarsal into the medial cuneiform was utilized and provided for adequate stabilization.

Adequacy of the reduction was assessed with both direct visualization and adjuvant fluoroscopy. After fixation of the first tarsometatarsal injury, the second metatarsal base/Lisfranc joint complex was evaluated to assess anatomical alignment. Finally, reconstruction of the medial column addressed the navicular injury. Direct exposure of the navicular provided for anatomical reduction and safe hardware placement (Fig. 12.6).

Figure 12.6

Intraoperative views of the medial column reconstruction

Fracture Reduction and Fixation (Lateral Column)

Attention was then focused on the lateral column injury focusing on the cuboid. A linear incision was made in line with the fourth metatarsal and extended proximally to ensure adequate visualization of the cuboid (Fig. 12.7). Subcutaneous branches of the superficial peroneal nerve are commonly seen after skin incision and should be gently dissected (Fig. 12.8). The interval between the peroneus tertius and peroneus brevis is exploited to reveal the underlying lateral wall of the cuboid. Further dissection proximally reveals the inferior aspect of the extensor digitorum brevis muscle belly. This was elevated as a full-thickness flap from the lateral cuboid (Fig. 12.9). Next, the articulations at the calcaneal cuboid and cuboid metatarsal joints were directly visualized (Fig. 12.10). Articular impaction was addressed with mobilization of the lateral cuboid cortical surface and elevation of the depressed articular segments to produce a congruent articular surface (Fig. 12.11). Any bone void should be addressed with supplemental graft material (i.e., allograft bone graft) and temporary K-wire fixation is placed to maintain the reduction. Definitive stabilization was accomplished with small fragment plate fixation. Contouring is usually necessary to ensure appropriate screw placement/trajectory and minimize hardware prominence. Newer anatomically contoured plates may be beneficial for certain fracture patterns. Additionally, angular stable screw fixation may be warranted for patients with severe comminution or osteoporotic bone (Fig. 12.12).