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

On Saturday last week, US President-Elect Joe Biden suffered midfoot fractures while playing with his dog. Initial media reports suggested that he had twisted his foot, and no obvious fractures were found after Mr. Biden attended an X-ray clinic on the Sunday. However, after a CT scan of his foot, the President-Elect’s personal physician confirmed he had sustained hairline fractures of the intermediate and lateral cuneiform bones and that he will need to wear a walking boot for several weeks.

Lee Parker, Consultant Orthopaedic Foot and Ankle Surgeon at OneWelbeck Orthopaedics, looks closer at cuneiform fractures and their significance.

What is a cuneiform fracture?

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.

How to treat a cuneiform fracture

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 .