Anteroposterior view X-ray of the foot.
Lateral view X-ray of the foot.
A 48-year-old woman presents with left foot pain from a fall 2 days prior to her visit. She complains of pain with weight bearing and has noticeable bruising over her midfoot. Anteroposterior and lateral X-rays (Figures 1 and 2) show a medial cuneiform fracture with mild displacement.
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Fractures of the midfoot are a relatively uncommon injury. The midfoot consists of 5 bones, including the navicular, cuboid, and the medial, middle, and lateral cuneiform. The bones of the midfoot are tightly bound together by strong dense plantar ligaments and are relatively immobile. Together, the bones and ligaments help maintain the normal arch of the foot during weight bearing. Injuries or deformity to the midfoot can significantly affect hindfoot and forefoot alignment.1,2
The medial, middle, and lateral cuneiform bones align side by side on the medial foot and provide rigid support to the medial longitudinal arch during weight-bearing activities. Cuneiform injuries are rare but can occur with an axial load and in association with tarsometatarsal joint injuries. An X-ray with 3 views of the foot should be obtained if a fracture to the cuneiform bones is suspected. Swelling, pain to palpation over the midfoot, or pain with weight bearing are indications for X-ray. If X-rays are negative with a suspected midfoot injury, then a single leg weight-bearing (stress view) X-ray should be obtained if possible to determine if instability is present. Disruption of the intercuneiform ligaments can occur and cause the cuneiform bones to spread apart with weight bearing (instability). CT is the most common follow-up study used if a fracture or instability is suspected but not apparent on X-ray. Displaced and unstable injuries of the cuneiform bones are treated with open reduction and internal fixation. Most cuneiform fractures are stable and nondisplaced or minimally displaced fractures can be treated in a non-weight-bearing boot or cast for 6 to 8 weeks. Walking on the foot may cause a cuneiform fracture to displace, so weight bearing is generally not recommend until the fracture heals radiographically.
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Moore D. Tarsal navicular fractures. https://www.orthobullets.com/foot-and-ankle/7033/tarsal-navicular-fractures. Accessed October 10, 2017.
- Early JS. Fractures and dislocations of the midfoot and forefoot. In: Bucholz RW, et al, eds. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006.