Cuboid nutcracker fracture in children: Management and results

Thomas Ruffing; Tilmann Rückauer; Frederic Bludau; Alexander Hofmann; Markus Muhm; Arnold J Suda

doi:10.1016/j.injury.2018.12.021

Cuboid nutcracker fracture in children: Management and results

Injury. 2019 Feb;50(2):607-612. doi: 10.1016/j.injury.2018.12.021. Epub 2018 Dec 17.

Authors

Thomas Ruffing¹, Tilmann Rückauer², Frederic Bludau³, Alexander Hofmann¹, Markus Muhm¹, Arnold J Suda⁴

Affiliations

¹ Westpfalz-Klinikum Kaiserslautern, Department of Trauma and Orthopaedics, Medical Faculty Mannheim, University of Heidelberg and University of Mainz, Hellmut-Hartert-Str. 1, 67655, Kaiserslautern, Germany.
² University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Department of Pediatric Surgery, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
³ University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Department of Orthopaedics and Trauma Surgery, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
⁴ University Medical Center Mannheim, Medical Faculty Mannheim of Heidelberg University, Department of Orthopaedics and Trauma Surgery, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany. Electronic address: arnold.suda@umm.de.

PMID: 30580927
DOI: 10.1016/j.injury.2018.12.021

Abstract

Introduction: Compression fractures of the cuboid bone in children and adolescents are rare. Fracture morphology, associated lesions, treatment options and long-term outcomes of this very rare injury are published in a few case reports. This study with review of the literature aims to support the understanding of fracture pattern and optimize pathways of decision making.

Material and methods: A retrospective two-center study was performed in a patient cohort treated between 2001 and 2016. All patients aged less than 18 years who sustained a cuboid fracture were included. Age, gender, mechanism of injury, fracture morphology, amount of displacement, associated injuries, and therapy were analyzed. In the follow-up (FU), the AOFAS Midfoot Scale was investigated.

Results: Fractures of the cuboid bone were diagnosed in 7 boys and 9 girls. The mean age of the patients was 10 years (range: 2.2-16.1 years). According to the classification of Fenton we detected 11 (69%) type 2, 2 (12%) type 3 and 3 (19%) type 5b fractures. Other fracture types according to Fenton were not observed. All children under 10 years sustained a type 2 fracture. Open reduction and internal fixation was performed in 5 (31%) patients. Bone grafting was not necessary. FU was performed in 14/16 patients on average after 9 years (mean; range: 1.4-16.2 years). The mean AOFAS Midfoot Scale at FU for extra-articular type 2 fractures was 100 points, whereas in intra-articular fractures (Type 3) and fractures associated with mid-tarsal disruption (type 5b) worse results were found (95 and 66 points, accordingly).

Conclusion: This rare injury shows inhomogenous morphologies and offers different treatment approaches. Extra-articular Fenton type 2 lesions are the most common type of cuboid fracture in children (69%). A potential loss of length of the lateral column must be considered. In contrast to adults, type 1, 4, and 5a fractures were not found in our cohort of children and adolescents. Lower scores of the AOFAS Midfoot Scale were found with either intra-articular involvement or associated midfoot lesions.

Keywords: Adolescents; Children; Cuboid fractures; Nutcracker fracture.

MeSH terms

Adolescent
Child
Child, Preschool
Female
Foot Injuries / diagnostic imaging*
Foot Injuries / physiopathology
Foot Injuries / surgery
Fracture Fixation, Internal / methods*
Fractures, Bone / diagnostic imaging*
Fractures, Bone / physiopathology
Fractures, Bone / surgery
Humans
Intra-Articular Fractures / diagnostic imaging*
Intra-Articular Fractures / physiopathology
Intra-Articular Fractures / surgery
Male
Radiography
Retrospective Studies
Tarsal Bones / diagnostic imaging
Tarsal Bones / injuries*
Treatment Outcome