Clinics and Practice 2018; volume 8:1093

studies showed no definitive abnormalities.

On magnetic resonance imaging (MRI), a
Not all ankle injuries are ankle
Correspondence: Sidharth Unnithan, Aster
sprains - Case of an isolated T1 weighted image showed continuous Medcity, Cochin, Kerala, India.
cuboid stress fracture hypointense signals at the infero-lateral E-mail: [email protected]
aspect of the cuboid bone and Fat sup-
pressed T2-weighted image showed hyper- Key words: Stress fracture; cuboid stress frac-
Sidharth Unnithan, Joe Thomas
ture; misdiagnosis; ankle injuries; sports med-
Aster Medcity, Cochin, Kerala, India intense signals. This was correlated with icine.
computed tomography (CT scan). There
were no other additional findings. Thus an Contributions: the authors contributed equally.
isolated cuboid stress fracture was diag-
nosed. The patient was advised to discontin- Received for publication: 22 June 2018.
Abstract ue prolonged physical activity and was Accepted for publication: 4 July 2018.
A 22-year old lady, had a twisting injury immobilized for 3 weeks (Figures 1 and 2).
We obtained written informed consent This work is licensed under a Creative
to her left ankle followed by pain on pro- Commons Attribution NonCommercial 4.0
longed weight bearing and walking. from the patient to publish this case report. License (CC BY-NC 4.0).
Magnetic resonance imaging with comput-
ed tomography correlation was done which ©Copyright S. Unnithan and J. Thomas 2018
showed an isolated cuboid stress fracture. Licensee PAGEPress, Italy
Isolated cuboid stress fractures are very rare Discussion and Conclusions Clinics and Practice 2018; 8:1093
doi:10.4081/cp.2018.1093
and are usually misdiagnosed as ankle Iwamoto and Takeda3 studied 196 cases
sprains. of stress fractures (125 fractures in males
and 71 in female) and noticed the most
common site was the tibial shaft (44.4%) nism of fracture of the cuboid bone is the
and followed by the foot (15%) and forced plantar flexion of the foot leading to
Introduction metatarsals (9.7%) and the tarsal (1%). the compression of the cuboid between the
Stress fractures of the foot are common- The study by Posinkovic and Pavlovic4 calcaneum and fourth and fifth metatarsals.
ly seen in athletes but are mainly seen at the detailed 113 stress fractures in soldiers of Therefore repeated plantarflexion may lead
calcaneum, navicular and the metatarsals.1 which majority were in the metatarsals and to the fracture. This mechanism was
Isolated cuboid stress fractures are rarely only 1 of 113 was in the cuboid bone. The explained earlier by Hermel and Gershon-
seen and diagnosed.2 We report a case of an study by Pester and Smith5 revealed only Cohen,17 known as the Nut in the
isolated cuboid stress fracture in a physical- one cuboid fracture among 1338 fractures Nutcracker which corresponds to the com-
ly active 22-year old lady. of the foot and the lower leg in soldiers. In pression of the cuboid between the calca-
a similar study, Yale6 reported no cuboid neum and the metatarsals.
fractures among 3657 fatigue fractures of Another hypothesis as stated by Chen et
the distal lower extremities in military al.10 was that the peroneal tendon passes
Case Report recruits. In contrast, cuboid stress fractures through the peroneal groove of the cuboid
are not rare among children. Oestreich and bone and it is the supporting point of the
A 22-year old female student came with Bhojwani7 through his studies came to a peroneal tendon. Thus repetitive pull by the
complaints of persistent pain and swelling conclusion that tarsal stress fractures in peroneal tendon on the cuboid bone through
on the left ankle and foot for 2 months. She children are not rare by detecting 188 stress the groove is responsible for the stress frac-
had a twisting inversion injury of her ankle fractures of the cuboid in 527 children. ture on the foot. Another hypothesis was by
followed by a fall, following which she was Greaney et al.8 studied 250 military recruits Goldman18 who stated that malalignment of
not able to bear weight immediately and with lower extremity fractures and detected the foot i.e. a pronated or cavus foot leads to
had swelling. She went to a local hospital 11 cases of cuboid stress fractures. Thus a stress fracture of the cuboid bone. A
where X-rays were taken and major frac- incidence varies based on various studies pronated foot leads to the wedging of the
tures were ruled out. She was advised and many cases usually go undetected. cuboid between the calcaneum and the
NSAID’s, crepe bandage and rest. She con- Literature from various studies shows 7 metatarsals due to marked forefoot abduc-
tinued with her daily activities and did not such case reports of cuboid stress frac- tion, thus leading to a stress fracture.
take rest as advised. Four weeks following tures1,9-14 in athletes (Table 1). All fractures Similarly, a cavus foot with increased
the injury she consulted a local orthopaedi- occurred in young athletes aged between weight bearing on the lateral column will
cian who advised her rest and NSAID’s, late teens and their early twenties. All of lead to stress fracture.
which was again not followed by her. them recovered by conservative treatment. In the current case, the most likely
After 6 weeks she presented to our hos- In most cases, it took more than 3 weeks to cause was excessive plantar flexion when
pital with complaints of persisting pain and diagnose the case showing the limited she fell leading to the crushing injury on the
swelling in her left ankle and foot. Her past awareness of the condition. The cases were cuboid bone and continuous plantar flexion
history and family history were not remark- diagnosed by MRI or bone scintigraphy. In on the foot while walking without rest has
able. She was walking with a limping gait our case, the patient was not an athlete. led to the stress fracture of the cuboid bone.
but could walk unaided. On examination, The mechanism of fracture is still under Since there are very few case reports on
there was no abnormality in alignment of hypothesis. Linder et al.15 in his studies stress fractures of cuboid bone and minimal
the lower extremities. No deformities were showed that cuboid fractures are associated research on its etiology, the mechanism of
noted in the lower extremities. There was with inversion ankle sprains and should be injury of cuboid bone still needs to be iden-
pain on single leg weight bearing with mild noted when there is localized lateral foot tified. More clinical studies or case reports
tenderness and swelling noted on the lateral pain or pain on forefoot mobilization. John in the future could give more information
side of foot and ankle. Plain radiographic et al.16 stated that the most likely mecha- on the mechanisms of injury.

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 Case Report

Table 1. Reported cases of cuboid stress fractures.

Age and gender Time from symptom Diagnostic method Treatment
onset to diagnosis
Mahler et al. (1993)1 20 y/Female 1 week Bone scintigraphy Non weight bearing
Beaman et al. (1993)9 22 y/Male 2 week Bone scintigraphy Plaster cast
20 y/Female 1 week Bone scintigraphy
Chen (1993)10 27 y/Female 1 week Computed tomography Rest
Matsumoto et al. (1996)11 16 y/Male 4 weeks Magnetic resonance imaging Brace
Battaglia et al. . (2002)12 20 y/Male 3 weeks Bone scintigraphy Plaster cast
Kawaharaet al. . (2010)13 17 y/Female 1 month Magnetic resonance imaging Splint
Hagino et al. (2014)14 17 y/Male 1 month Magnetic resonance imaging Brace
Present study 22 y/Female 6 weeks Magnetic resonance imaging Plaster cast

Figure 1. T1 weighted image showing continuous hypointense Figure 2. Fat suppressed T2-weighted image showing hyperin-
signals at the infero-lateral aspect of the cuboid bone. tense signals at the infero-lateral aspect of the cuboid bone.

Isolated cuboid stress fractures are 3. Iwamoto J, Takeda T. Stress fractures in 9. Beaman DN, Roeser WM, Holmes JR,
rarely diagnosed and are usually missed out athletes: review of 196 cases. J Orthop Saltzman CL. Cuboid stress fractures: a
due to misdiagnosis of an ankle sprain. We Sci 2003;8:273-8. report of two cases. Foot Ankle
thus report a rare case of an isolated cuboid 4. Posinkovic B, Pavlovic M. Stress frac- 1993;14:525-8.
stress fracture in a 22-year old physically tures. Lijec Vjesn 1989;111:228-31. 10. Chen JB. Cuboid stress fracture. A case
active young woman. In cases of persistent 5. Pester S, Smith PC. Stress fractures in report. J Am Podiatr Med Assoc
pain on the lateral side of the foot with no the lower extremities of soldiers in 1993;83:153-5.
radiographic findings, cuboid stress fracture basic training. Orthop Rev 11. Matsumoto A, Nishiyama T, Kimura S,
should be suspected and investigations such 1992;21:297-303. Masuko H. A case of cuboid stress frac-
as MRI or CT scan needs to be considered 6. Yale J. A statistical analysis of 3657 ture of the right foot. J Kansai Clin
to confirm the diagnosis. consecutive fatigue fractures of the dis- Sports Med Sci 1996;6:11-3.
tal lower extremities. J Am Podiatry 12. Battaglia H, Simmen HP, Meier W.
Assoc 1976;66:739-48. Stress fracture of the cuboid bone: an
7. Ostreich A, Bhojwani N. Stress frac- easy to treat rarity. Swiss Surg
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cas eof cuboid bone stress fracture in a 1986;12:380-2. nutcracker fracture of the cuboid by
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