What is the treatment for an avulsion fracture of the cuboid?

Treatment of Avulsion Fracture of the Cuboid

Non-operative management is the recommended treatment for avulsion fractures of the cuboid, which are typically non-displaced and stable. 1

Classification and Assessment

Avulsion fractures of the cuboid represent Type 1 fractures according to current classification systems, accounting for approximately 48.4% of all cuboid fractures. These involve simple avulsion injuries to the capsule of the calcaneo-cuboid joint 2.

When evaluating a cuboid avulsion fracture, consider:

• Degree of displacement (critical threshold is <1mm)
• Stability of the lateral column
• Integrity of surrounding joints (Chopart and Lisfranc)
• Mechanism of injury (typically low-energy)

Treatment Algorithm

Non-operative Management (First-line for most avulsion fractures)

• Indicated for:
  • Non-displaced avulsion fractures (<1mm displacement) 1
  • Low-energy trauma mechanisms
  • Intact lateral column length
  • No associated midfoot injuries

Non-operative Protocol

1. Immobilization:

   • Short leg walking boot or cast for 4-6 weeks
   • Weight-bearing status: Protected weight-bearing initially, progressing as tolerated

2. Pain Management:

   • NSAIDs if not contraindicated
   • Limited opioid use if necessary for acute pain

3. Rehabilitation:

   • Begin at approximately 4 weeks with gentle range of motion exercises
   • Progress to strengthening exercises after radiographic evidence of healing
   • Focus on proprioception and balance training

4. Follow-up:

   • Clinical and radiographic assessment at 2-week intervals initially
   • Monitor for:
     • Fracture healing
     • Maintenance of lateral column length
     • Return of normal foot mechanics

Surgical Management

• Reserved for:
  • Displaced avulsion fractures (>1mm)
  • Fractures with associated midfoot instability
  • Cases with disruption of the lateral column length

Surgical Options

• Open reduction and internal fixation (ORIF)
• Small fragment screws or suture anchors for avulsion fragments
• Bone grafting may be necessary if there is bone loss

Potential Complications

• Midfoot instability
• Post-traumatic arthritis
• Lateral column shortening
• Chronic pain
• Altered foot biomechanics

Important Considerations

• Cuboid fractures rarely occur in isolation; always evaluate for associated injuries to the Chopart and Lisfranc joints 1
• The cuboid is the cornerstone of the lateral column and maintains its length, which is critical for normal foot function
• Even seemingly minor avulsion fractures should be monitored to ensure proper healing and restoration of normal foot mechanics
• Radiographic assessment should include standard foot views and weight-bearing views when possible to assess stability

Pitfalls to Avoid

• Failing to recognize associated midfoot injuries
• Underestimating the importance of lateral column length maintenance
• Inadequate follow-up during the healing process
• Premature return to high-impact activities before complete healing

The most recent evidence supports that while isolated cuboid avulsion fractures are rare 3, they generally respond well to conservative treatment when non-displaced, with surgical intervention reserved for cases with significant displacement or associated midfoot instability 4, 5.