Cuneiform fractures are suddenly a hot topic – but what are they?

The cuneiforms make up three bones in the midfoot. These bones interlock with each other and are the bridge between the navicular and the metatarsals. The importance of these bones lies in their solid structure and the fact that they create a very stable medial column of the foot. This stability is extremely important in walking and running, as it allows muscles around the ankle and foot strength to propel the body forward.

Cuneiform fractures are very rare in isolation and are most often seen in the context of Lisfranc injuries of the foot. These are commonly-missed ligamentous injury that can also occur with fractures. As in Mr Biden’s case, it is important to look carefully for them with detailed cross-sectional imaging of the foot (CT or MRI scanning) since if missed, they can lead to mal-alignment of the midfoot bones and subsequent disabling arthritis.

The management of the injury is determined by thorough patient examination. Bruising on the sole of the foot (Fig. 1) often indicates internal fractures and ligament injuries and should prompt detailed imaging. X-rays may only reveal subtle signs of the injury such as a small bone fleck (Fig. 2) and most often a CT scan is needed (Figs. 3&4 show CT images with an intermediate cuneiform fracture and a base of 2nd metatarsal fracture where the stabilizing Lisfranc midfoot ligament is attached). If there are any signs of any mal-alignment or instability in the midfoot joints, surgery is most often performed (Figs. 5&6).

A standing CT scan is available at One Welbeck and can be useful to show both the fracture and whether or not the foot is unstable.

Non-operative treatment is reserved only for stable, perfectly-aligned midfoot joints and in President-Elect Biden’s case, he can expect at least 6 weeks in his walker boot followed by several weeks of physiotherapy.

Mr Lee Parker is a Consultant Foot and Ankle Surgeon at OneWelbeck Orthopaedics. A well-known figure within his specialty, Mr Parker has extensive experience in managing foot and ankle trauma. His NHS base is at The Royal London Hospital, one of Europe’s largest trauma centres. To schedule a consultation with Lee, please call +44 (0)203 653 2002 or email bookings.orthopaedics@OneWelbeck.com.