What is your diagnosis?

Nondisplaced avulsion fracture of the right cuboid (Type 1 Cuboid Fracture).

• Pearl: An isolated avulsion fracture of the cuboid is an uncommon injury, yet should be suspected in patients with dorsolateral foot pain and localized swelling following inversion ankle injuries, especially while the foot is in plantar-flexion. The avulsion fracture is secondary to stress placed on the cuboid from the calcaneal-cuboid ligament [1].

Image 3: Peter Martin’s image, oblique XR with annotated arrow of fracture

What is your initial workup in the ED?

Initial workup in the ED should consist of weight-bearing radiographs of the foot (if the patient is able to bear weight), including AP, oblique, and lateral views. Weight-bearing radiographs can help reveal unstable injuries to the midfoot, such as an associated Lisfranc injury, compared to non-weight bearing radiographs. 

• Pearl: In patients with acute ankle and foot injuries, one should remember the Ottawa Ankle Rules to guide decision making in regards to imaging. Ottawa Ankle Rules are positive (and imaging should be performed) if the patient has point tenderness at posterior aspect of either malleoli, navicular, or base of 5th metatarsal, or is unable to bear weight (as in our patient above) [2].

What imaging confirms the diagnosis?

When a cuboid fracture is suspected, XR is the initial recommended test. However, cuboid fractures (and other midfoot fractures) can be missed on XR. When clinical suspicion for such is present with negative XR, advanced imaging with CT or MRI should be strongly considered [3]. 

• Pearl: Fractures of the midfoot, including the cuboid, can lead to chronic pain and dysfunction if not treated appropriately. This is due to the cuboid’s function and role in providing stability in the foot’s longitudinal arch. Thus, if concern for an injury is present and XR is negative, advanced imaging is warranted [3].

What is your initial management and disposition?

Initial management of cuboid avulsion fractures is nonoperative, with placement of a CAM boot or short leg walking cast for 4-6 weeks. Weight bearing as tolerated is generally recommended. These can be managed by Orthopedics, Primary Care Sports Medicine, or primary care physicians with experience in fracture management [4,5]. 

What are the indications for surgical referral?

Immediate consultation is required for open fractures or those with neurovascular deficit. Otherwise, outpatient referral for surgical fixation is recommended in cuboid fractures that are comminuted, have >2 mm step off at any articular surface, or if the fracture is associated with any other foot or ankle fracture (such as of the cuneiforms or calcaneus) [4,5].