80
EEXOT
Volume 65, (2): 80-82, 2014
Open Dislocation
of the Medial Cuneiform:
A Case Report
Athanassios Hatzigiannakis, Georgios Kiziridis, Dimitrios Panagiotidis,
Dimitrios Zemadanis
Department of Ortopaedics, University General Hospital of Alexandroupolis, Greece
ABSTRACT
Isolated dislocation of the first cuneiform bone is an
extremely rare lesion. Few cases of this injury have been
previously described in the literature. The case presented
here is a previously unreported variant of first ray dorsomedial dislocation in combination with a diaphyseal fracture
of the second metatarsal. After fixation with a Kirschner
wire for the cuneiform and a small plate for the second
metatarsal, the foot was immobilized for 6 weeks. The
patient recovered uneventfully and remains asymptomatic
6 years later.
Keywords: medial cuneiform, dislocation, open, second
metatarsal fracture
INTRODUCTION
We present a rare case of an open dislocation of the
medial cuneiform and the treatment applied. This specific
report describes a previously unreported variant of first ray
dorsomedial dislocation in combination with a diaphyseal
fracture of the second metatarsal.
CASE REPORT
A twenty year old man was admitted to hospital after
a road accident while he was riding a bicycle. The patient
had an injury to the left foot with the following findings:
there was an extensive wound, which started from the
dorsal surface of the medial tarsometatarsal articulation,
turned to the plantar surface and extended to the whole
arch of the foot, while there was a dorsomedially displaced
bone of the tarsus, which was visible and almost denuded
of soft tissues. The circulation was intact. X-rays showed
a dorsomedial dislocation of the medial cuneiform in
combination with a diaphyseal fracture of the second
Correspondence to:
A. Hatzigiannakis, Ellis 8, 68100 Alexandroupolis, Greece
Email: [email protected], [email protected]
Figure 1: Anteroposterior radiograph of the left foot showing
the dislocation of the medial cuneiform and fracture of the
second metatarsal.
metatarsal (Figures 1,2).
Under general anesthesia, reduction of the dislocated
bone was obtained and held with a Kirschner wire. The
second metatarsal fracture was fixated by a small plate
(Figures 3,4), followed by a repair of the torn articular
capsule of the first dorsal and medial interosseous tarsometatarsal ligaments. The plantar aponeurosis was torn
Open Dislocation of the Medial Cuneiform: A Case Report
81
Figure 2: Lateral radiograph of the same foot showing the
above injuries.
Figure 4: Lateral radiograph of the reduced injury.
Six years postoperatively the patient walks without
any pain in the foot and has full mobility. There was
radiological confirmation of the normal position of the
first cuneiform, the absence of arthritis of the medial
tarsometatarsal joint, as well as the union of the second
metatarsal (Figures 5,6).
DISCUSSION
Figure 3: Anteroposterior radiograph showing the reduction
and stabilization of the dislocated cuneiform and the fracture of
the second metatarsal.
without extension into the deeper muscular layers. The
skin was closed only in the area of the dislocation and was
left open through the rest of its length.
The foot was immobilized in a below knee cast for six
weeks until the K-wire was removed. The wound healed
very satisfactorily by second intention. At examination five
months later, he was asymptomatic.
Dislocation of the medial cuneiform is a rare injury.
Up to day extremely few cases have been reported. The
mechanism of single dislocation or fracture is direct trauma.
A medial cuneiform fracture or dislocation is also possible
to happen in combination with other injuries of the tarsometatarsal articulations.
5
1
Hidalgo-Ovejero et al. (2005) and Aitken et al (2012)
have reported a similar case recently. Holstein and Jolders6
4
man (1950) , Dines et al. (1984) consider this as a variant
of Lisfranc’s dislocation. The reason for the presentation
9
of this case is its rarity. Schiller and Ray (1970) and
3
Compson (1992) have reported that medial cuneiform
can escape from routine x-rays. Because of this, there
should be a very comprehensive evaluation of the clinical
picture of the foot accompanied by oblique radiographs.
In our case, diagnosis was easy because of the displacement of the medial cuneiform through the wound and
the obvious radiological picture that showed a complete
separation of the medial cuneiform from the base of
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E.E.X.O.T., Volume 65, Issue 2, 2014
Figure 5: Anteroposterior radiograph 6 years post-injury
showing the normal position of the medial cuneiform and
absence of osteoarthritis of the joint.
Figure 6: Lateral radiograph 6 years post-injury showing the
normal relationship of tarsometatarsal joint of the foot.
the first metatarsal. Brown et al. (1975)2 reported a
distal and lateral dislocation of the medial cuneiform in
association with displacement of the second to fourth
metatarsals and small medial fractures of the navicular
8
and medial cuneiform. Levine et al. (1998) and Hubbell
7
et al. (1998) reported a plantar dislocation of the medial
cuneiform. Our report differs from other reported cases,
because it is a complete open dislocation in combination with fracture of the second metatarsal and not
with tarsometatarsal fracture-dislocation. The medial
cuneiform articulates with four bones. It makes up the
medial third of the naviculocuneiform joint and is held
tightly to the middle cuneiform and to the bases of the
first and second metatarsals. The injury mechanism was
the direct strike on the foot in accordance to the view
9
of Schiller and Ray (1970) .
REFERENCES
CONCLUSION
A medial cuneiform dislocation is difficult to reduce
only by manipulation. Open reduction of the dislocation
is relatively easy and is required when the anterior tibial
tendon insertion is trapped between the first and second cuneiforms or the medial cuneiform and navicular
3
(Compson, 1992) . In our case, we did not face such a
problem, because the dislocation was open and reduced
easily into position.
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