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First published on September 16, 2005, doi:10.1177/0363546505275012
This version was published on January
1, 2006
The American Journal of Sports Medicine 34:21-23 (2006)
© 2006 American Orthopaedic Society for Sports Medicine
Complete Cuboid Dislocation in a Professional Baseball Player
J. Steve Smith, MD* and
A. Samuel Flemister, MD
From the Department of Orthopaedics, University of Rochester, Rochester, New York
* Address correspondence to J. Steve Smith, MD, Department of Orthopaedics, University of Rochester, 601 Elmwood Avenue, Box 665, Rochester, NY 14642 (e-mail: jstevesmith{at}msn.com).
Key Words: cuboid dislocation • foot trauma • baseball injuries • lateral column injuries
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INTRODUCTION
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Cuboid dislocations are uncommon orthopaedic injuries. There are fewer than 10 reported cases of this type of injury,2,3,5,7–12 with only 5 of those being complete dislocations. The exact mechanism of a cuboid dislocation is unknown. Most cases involve high-energy trauma or inversion plantar flexion injuries.
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CASE REPORT
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A 23-year-old professional baseball player attempted to avoid being tagged out at home plate by sliding around the opposing team’s catcher. During his slide, his left foot was caught underneath his body. He had immediate ankle pain and deformity and was unable to ambulate. His ankle was immobilized at the scene, and he was sent by ambulance to the emergency department. On examination, the patient had gross deformity of the ankle consistent with an ankle or subtalar dislocation. He was neurovascularly intact. Because of threatened soft tissues around the ankle, an urgent closed reduction was performed, and prereduction radiographs were not obtained. The closed reduction was performed without difficulty, and the initial skin tenting was relieved. However, the postreduction radiographs showed a dislocation of the cuboid and a possible fracture at the base of the fourth metatarsal (Figures 1
and 2). A subsequent CT scan confirmed a plantar medially dislocated cuboid and a comminuted fracture of the base of the fourth metatarsal, as well as a fracture along the plantar aspect of the lateral cuneiform. There was no fracture of the cuboid (Figure 3). The patient was taken to the operating room the next day for closed or open reduction of the dislocated cuboid. Under general anesthesia, closed reduction of the cuboid was attempted without success. An incision was then made on the lateral aspect of the foot distal to the fourth metatarsal base and carried proximally to the calcaneocuboid joint. The extensor digitorum brevis muscle was elevated and retracted, being careful to avoid damage to the dorsal cutaneous nerves. The calcaneocuboid joint was visualized and noted to be incongruent. Inspection of the cuboid and fourth and fifth metatarsal joints revealed complete dislocation with interposed capsular tissue. After removal of the soft tissue interposition, the cuboid reduced but the metatarsal-cuboid articulation remained unstable. Therefore, two 1.6-mm Kirschner wires were placed percutaneously (distal to proximal) from the fourth and fifth metatarsals to the cuboid. The joint was then found to be stable. The rest of the midfoot was stressed (including the Lisfranc joint), and no subluxation was noted. The small fracture fragments from the metatarsals and lateral cuneiform were not well visualized in the wound, and no attempt was made to remove them. Intraoperative radiographs confirmed a congruent reduction of the cuboid (Figures 4 A and B). The wounds were closed, and the patient was placed into a plaster posterior splint and side struts.
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Figure 1. Anteroposterior and oblique foot radiographs of the foot demonstrating a cuboid dislocation.
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Figure 4. A, intraoperative foot radiograph showing Kirschner wire fixation and reduction of the cuboid dislocation. B, intraoperative lateral foot radiograph showing Kirschner wire fixation and reduction of the cuboid dislocation.
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The patient’s postoperative course consisted of pin removal at 6.5 weeks with continued nonweightbearing activity for 8 weeks from the time of surgery. Gradual weightbearing activity in a fracture walker boot and a formal rehabilitation program were then begun. Twelve weeks postoperatively, the patient had returned to regular shoe wear. At 7 months from the date of injury, the patient had achieved ankle and hindfoot range of motion and strength equal to the contralateral extremity and was cleared for return to full athletic activity. Weightbearing radiographs of his foot taken at that time showed no malalignment or arthrosis (Figures 5 A and B). One year from the date of the injury, the patient had returned for a full season of professional baseball.
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Figure 5. A, postoperative weightbearing oblique radiograph of the foot at 7 months from surgery. The cuboid has remained reduced. B, postoperative weightbearing lateral radiograph of the foot at 7 months from surgery. The cuboid has remained reduced.
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DISCUSSION
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The cuboid is a rigid and static stabilizer of the lateral column of the foot. It is the only bone to articulate with both the midtarsal and tarsometatarsal joints. These articulations give the cuboid marked stability, which is reinforced by multiple ligamentous, tendinous, and soft tissue attachments that include the dorsal and plantar ligaments, the peroneus longus tendon, and the plantar fascia.1,6,9 Therefore, dislocation or subluxation of the cuboid is uncommon. In 1937, Penhallow12 first reported a partial cuboid dislocation. This report was followed in 1969 by the study of Drummond and Hastings5 of an inferomedial cuboid dislocation. In fact, there have been only a few subsequent reports of cuboid dislocation or subluxation during the past 35 years.2,3,5,7–12
The full extent of this patient’s injury is unknown, as radiographs were not performed until after a closed reduction attempt had relieved the initial deformity. The patient’s initial deformity was consistent with a subtalar dislocation; however, there were no findings on the subsequent CT scan to suggest this diagnosis. In addition, we are not aware of any reports in the literature of associated cuboid and subtalar dislocations. The diagnosis of a residual cuboid dislocation in this patient was made based on plain radiographs. However, because the foot has multiple joints and bones that superimpose each other on plain radiographs, a CT scan may be necessary to further define the injury pattern and look for associated fractures.
Only 1 case of a successful closed reduction has been reported.7 Open reduction is usually required. As with any joint dislocation, soft tissue interposition often prevents reduction, and there are reports of the peroneus longus tendon specifically preventing reduction.4 In this patient, the interposed capsular tissue between the metatarsals and the cuboid prevented reduction. After removal of the soft tissues, the joint remained unstable, and further fixation was required. Both screw fixation and pin fixation, using a variety of configurations, have been described.1,2,4,5,9 In this high-level athlete, pins were chosen to minimize joint damage and stiffness. The pins were left in for about 6 weeks, as this protocol was felt to allow for adequate ligamentous healing and stability but prevent arthrofibrosis of the inherently mobile lateral column. Open reduction combined with temporary percutaneous fixation with Kirschner wires allowed this professional baseball player to return to his previous level of competition in a short period of time without significant sequelae.
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ACKNOWLEDGMENTS
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We thank Dr Timothy Kremchek and Dr James Amis for their help with this case report.
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FOOTNOTES
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No potential conflict of interest declared.
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REFERENCES
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- Andermahr J, Helling HJ, Maintz D, Monig S, Koebke J, Rehm KE. The injury of the calcaneocuboid ligaments. Foot Ankle Int. 2000;21:379–384.[ISI][Medline][Order article via Infotrieve]
- Buscemi MJ Jr, Page BJ II. Transcuneiform fracture: cuboid dislocation of the midfoot. J Trauma. 1986;26:290–292.[ISI][Medline][Order article via Infotrieve]
- Dewar FP, Evans DC. Occult fracture-subluxation of the midtarsal joint. J Bone Joint Surg Br. 1968;50:386–388.
- Dobbs MB, Crawford H, Saltzman C. Peroneus longus tendon obstructing reduction of cuboid dislocation: a report of two cases. J Bone Joint Surg Am. 2001;83:1387–1391.[Free Full Text]
- Drummond DS, Hastings DE. Total dislocation of the cuboid bone: report of a case. J Bone Joint Surg Br. 1969;51:716–718.
- Ebraheim NA, Lu J, Haman SP, Yang H, Yeasting RA. Cartilage and synovium of the peroneocuboid joint: an anatomic and histological study. Foot Ankle Int. 1999;20:108–111.[ISI][Medline][Order article via Infotrieve]
- Fagel VL, Ocon E, Cantarella JC, Feldman F. Case report 183: dislocation of the cuboid bone without fracture. Skeletal Radiol. 1982;7:287–288.[CrossRef][ISI][Medline][Order article via Infotrieve]
- Gough DT, Broderick DF, Januzik SJ, Cusack TJ. Dislocation of the cuboid bone without fracture. Ann Emerg Med. 1988;17:1095–1097.[CrossRef][ISI][Medline][Order article via Infotrieve]
- Kolker D, Marti CB, Gautier E. Pericuboid fracture-dislocation with cuboid subluxation. Foot Ankle Int. 2002;23:163–167.[ISI][Medline][Order article via Infotrieve]
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- McDonough MW, Ganley JV. Dislocation of the cuboid. J Am Podiatry Assoc. 1973;63:317–318.[Medline][Order article via Infotrieve]
- Penhallow DP. An unusual fracture: dislocation of the tarsal scaphoid with dislocation of the cuboid. J Bone Joint Surg Am. 1937;19:517–519.[Free Full Text]
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INTRODUCTION
CASE REPORT
