IS Case 587: Medial cuneiform fracture

Nicholas Perry, MD

Imaging Sciences URMC


Imaging Sciences URMC 2010
Publication Date: 2011-11-17

History

Patient is a 36-year-old female presenting to the ED with 10/10 left foot pain while playing soccer. She fell with excessive plantar flexion of the foot and was not able to subsequently bear weight.

Findings

Plain x-rays of the left foot demonstrated significant dorsal soft-tissue swelling without an obvious fracture. There was suggestion of cortical irregularity at the medial aspect of the 1st cuneiform, though artifact was also a consideration. Subsequent CT evaluation clearly shows a non-displaced comminuted fracture of the medial left cuneiform.

Discussion

Fractures of the foot are common though cuneiform fractures are typically less seen. These fractures generally occur in conjunction with other fractures of the midfoot such as Lisfranc fractures. However, isolated cuneiform fractures are more rare with few cases reported. This patient had no definitive gross fractures evident on plain radiographs, though there were two findings of particular interest: 1) subtle possible cortical irregularity of the medial cuneiform on oblique view (Fig. 2) and 2) significant dorsal soft-tissue swelling. The standard AP view (not shown) was negative and not helpful. Due to this hint of bone disturbance in the context of indirectly-apparent significant injury to the foot, a CT scan was performed. The CT scan clearly shows an obvious comminuted, non-displaced, isolated medial cuneiform fracture (Figs. 3 and 4).

This case emphasizes several important teaching points. Midfoot fractures are often difficult to detect as this area is a common blind spot of the foot with multiple overlapping structures. Due to the limitation with standard radiographs, careful and attentive evaluation of the region is always necessary, especially when no other pertinent findings are made. Secondary signs may be a helpful clue, such as soft-tissue swelling which could relate to the degree or possibly mechanism of injury. With a high index of suspicion, it is often necessary to obtain a more definitive imaging study in order to readily elucidate a fracture of the midfoot.

References

  1. Olson RC, Mendicino SS, Rockett MS. Isolated medial cuneiform fracture: review of the literature and report of two cases. Foot Ankle Int. 2000 Feb;21(2):150-3. PMID: 10694028
  2. Patterson RH, Petersen D, Cunningham R. Isolated fracture of the medial cuneiform. J Orthop Trauma. 1993;7(1):94-5. PMID: 8433209

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