01Approach to the Critical Patient/attcp41

Red flag recognition

›Neurovascular compromise indicators

›Absent or diminished dorsalis pedis pulse

›Immediate vascular surgery consultation

›Ankle-brachial index measurement

›Paresthesias or numbness in toes

›Compartment syndrome concern

›Neurovascular injury

›Pallor or cyanosis of forefoot

›Arterial injury until proven otherwise

›Compartment syndrome triggers

›Pain out of proportion to injury

›Tense swelling of midfoot

›Pain with passive toe dorsiflexion

›High-energy mechanism with significant swelling

›Fall from height

›Motor vehicle collision

›If compartment syndrome suspected, emergent orthopedic consult

›Compartment pressure measurement

›Fasciotomy threshold: pressure > 30 mmHg or within 30 mmHg of diastolic

Immediate priorities

›Stabilization steps

›Ice and elevation of affected extremity

›Target limb above heart level

›Reduces swelling and pain

›Analgesia initiation

›NSAID plus acetaminophen combination first-line

›Opioid reserve for severe or refractory pain only

02History/hx53

Mechanism of injury

›Traumatic mechanisms

›Direct blow to dorsal midfoot

›Most common mechanism (~46%)

›Crush injuries, dropped objects

›Axial loading

›~31% of cases

›Landing from jump, stepping off curb

›Avulsion or twisting mechanism

›~23% of cases

›Tarsometatarsal ligament avulsion concern

›Higher Lisfranc injury risk with twisting of plantarflexed foot

Stress fracture context

›Insidious onset pattern

›Repetitive subthreshold loading

›Athletes: runners, jumpers, hockey players

›Military recruits during basic training

›Metabolic bone disease contributors

›Vitamin D deficiency

›Female athlete triad: low energy availability, menstrual dysfunction, low bone density

›Gradual worsening dorsal midfoot pain with activity

Symptom characterization

›Pain features

›Dorsal midfoot pain

›Worse with weight-bearing

›Inability to push off with forefoot

›Onset timing

›Acute traumatic versus insidious stress fracture

03Physical Exam/exam49

Vitals and general

›Hemodynamic assessment

›Generally normal in isolated cuneiform fracture

›Hypotension or tachycardia suggests polytrauma or significant hemorrhage

›High-energy mechanisms require full trauma assessment

Inspection and neurovascular

›Visual assessment

›Dorsal midfoot swelling and ecchymosis

›Location relative to cuneiform bones

›Plantar ecchymosis

›Red flag for Lisfranc injury or significant midfoot disruption

›Skin integrity

›Open fracture exclusion

›Skin tenting over fracture site

›Neurovascular exam

›Dorsalis pedis pulse

›Quality and symmetry compared to contralateral side

›Posterior tibial pulse

›Capillary refill of toes

›Sensation assessment

›Light touch and two-point discrimination

›First web space: deep peroneal nerve territory

Palpation and provocative tests

›Point tenderness localization

›Each cuneiform individually palpated

›Medial cuneiform: most commonly fractured

›Intermediate cuneiform: smallest, most protected

›Lateral cuneiform: articulates with cuboid

04Differential Diagnosis/ddx40

Cannot-miss diagnoses

›Lisfranc fracture-dislocation

›ICD-10: S93.325 — dislocation of tarsometatarsal joint

›Critical diagnosis: ~20% initially overlooked

›Plantar ecchymosis, widened first–second metatarsal base gap on weight-bearing radiograph

›Cuneiform fracture may be only visible sign of Lisfranc complex disruption

›Compartment syndrome of foot

›ICD-10: M79.3

›Pain out of proportion, tense swelling, pain with passive stretch

›Surgical emergency requiring fasciotomy

Midfoot fractures

›Navicular fracture

›ICD-10: S92.25

›Dorsomedial tenderness; frequently occult on radiographs

›Stress fractures common in athletes

›Cuboid fracture

›ICD-10: S92.21

›Lateral midfoot pain

›Nutcracker fracture from abduction mechanism

›Metatarsal base fracture

›ICD-10: S92.31–S92.35 depending on bone

›Overlapping location with cuneiform tenderness

›Multiple metatarsal base fractures suggest Lisfranc complex injury

›Fifth metatarsal avulsion fracture

›ICD-10: S92.351

›Peroneus brevis avulsion at styloid process

›Ottawa rules address this specifically

05Laboratory Tests/lt28

Routine labs

›Standard isolated fracture

›Routine labs generally not indicated for isolated cuneiform fractures

›No infection, metabolic, or systemic concern

›Pre-operative labs if surgical management planned

›CBC, electrolytes, renal function, coagulation

›Type and screen if significant blood loss anticipated

Metabolic bone workup

›Stress or insufficiency fracture evaluation

›Vitamin D (25-OH) level

›Deficiency implicated in cuneiform insufficiency fractures

›Target: > 50 nmol/l

›Calcium and phosphorus

›Metabolic bone disease screening

›Alkaline phosphatase

›Bone turnover marker

›TSH and PTH if recurrent stress fractures

›Hyperparathyroidism and hypothyroidism as contributors

Infection and special circumstances

›Open fracture or infection concern

›CBC with differential

›Leukocytosis in infection or open fracture

›CRP

›Inflammatory marker for infection monitoring

›Blood cultures if systemic infection signs

›Prior to antibiotics

›Diabetic patients

›HbA1c

06Diagnostic Tests/dt85

Scoring Systems

›Ottawa Foot and Ankle Rules

›Approximately 100% sensitivity for clinically significant midfoot fractures

›ACEP Level B recommendation for application in acute foot injury

›Meta-analysis sensitivity 97%, specificity 31% for midfoot fractures

›Midfoot rule criteria

›Bone tenderness at navicular

›Bone tenderness at base of fifth metatarsal

›Inability to bear weight for 4 steps immediately and in ED

›Limitation for cuneiform fractures

›Cuneiform-specific tenderness not explicitly addressed in Ottawa rules

›Clinical suspicion may warrant imaging despite negative Ottawa rules

›Mehlhorn Classification system

›Type classification

›Type 1: fracture only

›Type 2: dislocation only

›Type 3: fracture-dislocation

›Subtype classification

›Subtype A: single cuneiform involved

›Subtype B: two cuneiforms involved

›Subtype C: all three cuneiforms involved

›Prognostic significance

›More bones involved and fracture-dislocations associated with worse outcomes

›Type 3C injuries have highest complication rates

MRI

›MRI indications for cuneiform fracture

›Gold standard for stress fractures and occult traumatic fractures

›Detects bone marrow edema before fracture line visible on radiographs

›Identifies stress reactions prior to complete fracture

›Ligamentous injury evaluation

›Lisfranc ligament complex integrity

›Plantar ligaments of tarsometatarsal joints

›Protocol considerations

›STIR and T2-weighted sequences most sensitive for marrow edema

›T1 for fracture line delineation

›Gadolinium generally not required for fracture assessment

›MRI performance characteristics

›Superior sensitivity for occult fractures compared to CT

›Radiographs occult in ~73% of isolated medial cuneiform fractures

›MRI identifies fractures when CT may be negative for stress reactions

›Timing consideration

›Can be performed immediately after injury

›Does not require delay unlike follow-up radiographs

CT

›CT indications

›Inconclusive radiographs with high clinical suspicion

›ACEP Level B: CT recommended when radiographs negative but suspicion remains

›ACR Appropriateness Criteria: CT usually appropriate for acute midfoot trauma

›Fracture characterization

›Best modality for displacement assessment

›Comminution pattern

›Intra-articular extension

›Surgical planning

›Three-dimensional reconstruction for operative planning

›Associated fracture identification

›CT performance characteristics

›Sensitivity for midfoot fractures superior to radiographs

›Radiograph sensitivity for midfoot fractures 25%–33%

›CT identifies occult fractures missed on plain films

›Limitations

›Less sensitive than MRI for stress reactions without fracture line

›Radiation exposure consideration especially in younger patients

›Standard radiograph role

›First-line imaging: weight-bearing AP, lateral, and oblique foot radiographs

›Weight-bearing critical for Lisfranc assessment

›Oblique view best for cuneiform visualization

›Radiograph findings

›Displacement assessment

›Associated metatarsal base fractures

›First–second metatarsal base gap > 2 mm on weight-bearing suggests Lisfranc injury

Ultrasound

›Point-of-care ultrasound role

›Emerging evidence for cortical disruption detection

›Not yet standard of care for cuneiform fractures

›Periosteal thickening and cortical step-off may be visualized

›Soft tissue assessment

›Hematoma extent

›Tendon integrity of extensor tendons

›Doppler assessment

›Vascular flow when neurovascular compromise suspected

›Dorsalis pedis artery patency

›Bone scan alternative

›High sensitivity for stress fractures when MRI unavailable

›Three-phase technetium-99m bone scan

›Increased uptake within 24–48 hours of stress fracture

›Limitations

›Lower specificity than MRI

›Radiation exposure

›Poor anatomic detail for surgical planning

07Disposition/dispo43

Discharge criteria

›Safe discharge requirements

›Fracture pattern suitable for conservative management

›Nondisplaced or minimally displaced fracture

›No dislocation component

›Functional and pain criteria

›Adequate pain control with oral analgesia

›Ability to use crutches or CAM boot safely

›Social criteria

›Reliable follow-up arranged within 1–2 weeks

›Home environment suitable for non-weight-bearing or protected weight-bearing

›Appropriate support at home

Admission indications

›Hospital admission required

›Open fracture

›IV antibiotics, operative debridement

›Orthopedic surgery involvement

›Compartment syndrome

›Emergent fasciotomy required

›High-energy polytrauma

›Associated injuries requiring monitoring

›Significant swelling with compartment monitoring required

›Serial examinations and pressure measurements

Orthopedic referral

›Referral indications and timing

›Emergent referral

›Open fracture

›Neurovascular compromise

08Treatment/t94

Initial ED management

›Immediate stabilization

›Ice application

›20 minutes on, 20 minutes off

›Reduces swelling and provides analgesia

›Elevation

›Limb above heart level

›Optimizes venous and lymphatic drainage

›Immobilization

›Posterior splint or CAM boot

›Non-weight-bearing until fracture type determined

Analgesia

›First-line oral analgesia

›Ibuprofen

›400–600 mg PO every 6–8 hours with food

›Maximum 2400 mg per day

›Combination with acetaminophen provides superior pain relief vs opioids alone

›Acetaminophen

›1000 mg PO every 6–8 hours

›Maximum 4000 mg per day (3000 mg in elderly or hepatic impairment)

›Topical NSAIDs

›ACP/AAFP guidelines recommend as primary treatment for musculoskeletal injuries

›Fewer systemic adverse effects than oral NSAIDs

›Diclofenac gel 1% applied to affected area 4 times daily

›NSAID safety considerations

›No conclusive clinical evidence that NSAIDs impair fracture healing

›Orthopaedic Trauma Association recommends routine NSAID use in fracture analgesia

›Contraindications and cautions

›Renal insufficiency: avoid or dose-reduce

›Heart failure: avoid

›GI bleeding history: add gastroprotection or switch to topical

›Elderly: increased risk of GI, renal, and cardiovascular adverse effects

›Opioid analgesia

›Reserve for severe or refractory pain

›ACEP recommends non-opioid agents as first-line for most acutely painful conditions

›Short course only: 3–5 days maximum

›Risk considerations

›6% of low-risk patients develop prolonged opioid use after acute injury

›Avoid in patients with substance use disorder history without careful risk stratification

›Sub-dissociative ketamine

›Alternative to opioids for severe pain

›0.1–0.3 mg/kg IV

›ACEP endorses as opioid-sparing strategy

›Regional anesthesia

›Ankle nerve block for procedural analgesia

›Superficial peroneal nerve block for dorsal foot

›Deep peroneal nerve block for first web space

›Effective for reduction or wound irrigation

Conservative management

›Nondisplaced or minimally displaced fractures (~55% of cases)

›Immobilization strategy

›Short leg walking cast or CAM boot for 6 weeks

›Weight-bearing as tolerated in stable fractures

›Transition phase

›Followed by 6 weeks of hard-soled shoe with arch support orthotic

›Gradual return to activity guided by symptoms

›Radiographic monitoring

›Repeat radiographs every 2 weeks to monitor alignment

›Ensure no displacement during healing

›Stress fractures

›Heal with immobilization alone without surgical intervention

›CAM boot for 6 weeks

›Activity modification: eliminate provocative loading

›Metabolic optimization

›Vitamin D supplementation if deficient: 1000–2000 IU daily

›Calcium intake 1000–1200 mg/day

›Address female athlete triad components if present

Surgical management

›Surgical indications

›Comminuted fractures with significant displacement

›Concurrent dislocation (Mehlhorn Type 2 or Type 3)

›Closed reduction frequently fails without internal fixation

›Intra-articular fractures with persistent pain after conservative management

›Failed conservative management with malunion or nonunion

›Surgical options

›Open reduction and internal fixation (ORIF)

›Preferred for displaced fractures amenable to fixation

›Plate or screw fixation

›Primary arthrodesis

›Severely comminuted or intra-articular injuries

›Tarsometatarsal joint fusion

›Indicated when articular surface reconstruction not feasible

›Post-operative management

›Non-weight-bearing for 6–8 weeks post-operatively

›Progressive weight-bearing protocol after radiographic healing evidence

›Physical therapy for range of motion and strengthening

Open fracture management

›Antibiotic protocol

›Cefazolin 2 g IV within 1 hour of open fracture identification

›Class I recommendation for open fracture prophylaxis

›Continue for 24 hours post-operatively

›Gram-negative coverage if contaminated wound

›Add gentamicin 3–5 mg/kg IV daily

›Tetanus prophylaxis

›Tetanus toxoid if vaccination not up to date

›Wound care

›Saline irrigation of wound

›Sterile dressing application

›Do not replace extruded tissue without surgical consultation

09Special Populations/sp77

Pregnancy

›Anatomical and physiological considerations

›Increased laxity of ligaments due to relaxin

›May predispose to associated ligamentous injury with fracture

›Lisfranc injury risk potentially higher with ligament laxity

›Altered gait and foot biomechanics

›Weight redistribution during pregnancy

›Increased midfoot stress

›Edema making clinical examination less reliable

›Baseline pedal edema common in pregnancy

›Imaging considerations

›Radiographs acceptable with abdominal shielding

›Foot radiograph radiation dose is negligible to fetus

›Document indication and shielding in chart

›MRI preferred over CT when advanced imaging required

›No ionizing radiation

›Avoid gadolinium in first trimester unless essential

›Medication safety

›NSAIDs: caution

›Avoid after 20 weeks: premature ductus arteriosus closure risk

›First trimester use acceptable for short term

›Acetaminophen preferred analgesic throughout pregnancy

›Opioids: use with caution

›Neonatal abstinence syndrome risk with prolonged use

›Short-course only for severe pain

›Ketamine: limited data in pregnancy; use only if clearly indicated

Geriatric

›Physiological considerations

›Increased fracture risk

›Osteoporosis and osteopenia prevalent

›Low-energy mechanisms can cause significant fractures

›Delayed diagnosis risk

›Atypical presentations more common

›Reduced pain perception in some patients

›Comorbidity burden

›Polypharmacy interactions with analgesics

›Renal and hepatic impairment affects drug dosing

›NSAID precautions in elderly

›Increased risk of GI bleeding, renal impairment, and cardiovascular events

›Use lowest effective dose for shortest duration

›Add proton pump inhibitor gastroprotection

›Acetaminophen: preferred first-line

›Maximum 3000 mg per day in elderly

›Avoid opioids where possible

›Increased fall risk, delirium risk, constipation

›Rehabilitation considerations

›Early mobility planning critical to prevent deconditioning

›Physical therapy referral

›Assistive device prescription

›Metabolic bone disease workup

›Vitamin D and calcium supplementation routinely indicated

›DEXA scan referral if not previously performed

›Bisphosphonate initiation discussion with primary care

Pediatrics

›Unique anatomical considerations

›Growth plate (physis) vulnerability

›Cuneiform ossification centers appear between ages 1 and 4 years

›Physeal fractures in skeletally immature patients

›Salter-Harris classification applies to physeal injuries

›Bone elasticity

›Higher proportion of cartilage makes fractures different from adults

›Buckle (torus) fractures more common

›Stress fracture considerations in pediatrics

›Rising incidence with increased youth sports participation

›Overuse injuries in young athletes

›Female athlete triad in adolescent girls

›Lower threshold for MRI

›Avoids radiation and superior for physeal injury assessment

›Treatment modifications

›Conservative management generally preferred

›Short leg cast for 4–6 weeks

›Weight-bearing as tolerated if stable

›Surgical threshold higher than adults

›Remodeling potential significant in younger children

›Medication dosing

›Ibuprofen: 5–10 mg/kg PO every 6–8 hours; maximum 40 mg/kg per day

›Acetaminophen: 10–15 mg/kg PO every 4–6 hours; maximum 75 mg/kg per day

›Non-accidental trauma consideration

›Mechanism inconsistent with injury pattern

›Child protective services referral if suspected

10Background/b79

Epidemiology

›Incidence and prevalence

›Cuneiform fractures are the least common foot fractures

›Extensive ligamentous stabilization of midfoot accounts for rarity

›Rare injuries due to protected anatomic position

›Medial cuneiform most commonly fractured

›Largest of the three cuneiform bones

›Articulates with navicular, intermediate cuneiform, first and second metatarsals

›Diagnostic challenge

›Initial radiographs occult in approximately 73% of isolated medial cuneiform fractures

›Mean diagnostic delay of approximately 65 days reported

›Frequently misdiagnosed as midfoot sprain

›Population distribution

›Athletes and military recruits disproportionately affected

›Stress fractures from repetitive loading

›High-energy trauma mechanism in general population

›Direct blow accounts for approximately 46% of cases

›Axial loading approximately 31%

›Avulsion approximately 23%

›Lisfranc co-injury prevalence

›Concurrent Lisfranc injury in subset; cuneiform fracture may be sentinel finding

Pathophysiology

›Anatomical basis

›Cuneiform bone anatomy

›Medial (first), intermediate (second), and lateral (third) cuneiform bones

›Wedge-shaped tarsal bones forming keystone of medial longitudinal arch

›Each cuneiform articulates with 4 other bones: contributing to midfoot stability

›Ligamentous complex

›Extensive interosseous, dorsal, and plantar ligaments

›Lisfranc ligament: oblique band from medial cuneiform to second metatarsal base

›This ligament has no analog between first and second metatarsals: anatomic vulnerability

›Fracture mechanisms

›Direct impact

›Crush force transmits through dorsal cortex

›Comminution common with severe direct trauma

›Indirect axial load

›Compressive forces transmitted through metatarsals

›Fracture at zone of maximal stress concentration

›Avulsion

›Ligament or tendon insertion traction fractures

›Tibialis anterior avulsion from medial cuneiform

›Stress and insufficiency mechanisms

›Repetitive loading exceeds bone remodeling capacity

›Vitamin D deficiency reduces bone mineralization threshold

›Complications and natural history

›Post-traumatic arthritis

›Each cuneiform articulates with multiple bones

›Intra-articular fractures carry highest arthritis risk

›Malunion and nonunion

›Displacement during healing alters midfoot biomechanics

›Arch collapse with medial cuneiform malunion

›Peroneus longus tendon dysfunction

›Scar or callus formation during healing can impair tendon gliding

›Chronic midfoot pain

›Reported in subset despite adequate initial treatment

Therapeutic Considerations

›Evidence base for conservative management

›Nondisplaced fractures: generally good prognosis

›Return to full function in 3–6 months with conservative management

›Stress fractures heal with immobilization alone without surgery

›Weight-bearing protocol

›Short leg walking cast or CAM boot for 6 weeks

›Followed by 6 weeks of hard-soled shoe with arch support

›Radiographic surveillance

›Every 2 weeks during immobilization to detect displacement

›Surgical evidence

›Concurrent dislocation: closed reduction frequently fails

›Internal fixation required for Mehlhorn Type 2 and Type 3 injuries

›ORIF versus primary arthrodesis

›ORIF preferred when articular surface reconstructable

›Primary arthrodesis for severely comminuted or irreparable articular injury

›Outcome data

›Multiple cuneiform involvement and fracture-dislocations associated with worse outcomes

›Single cuneiform nondisplaced fractures have favorable prognosis

›Analgesic evidence

›NSAID plus acetaminophen combination superior to opioids alone for closed fractures

›BMC Emergency Medicine 2024 randomized clinical trial evidence

›Equivalent or superior analgesia with fewer adverse effects

›ACEP policy: non-opioid agents first-line for most acutely painful conditions

›Sub-dissociative ketamine as opioid-sparing adjunct

›AAFP/ACP guidelines: topical NSAIDs recommended for non-low back musculoskeletal injuries

›Fewer systemic adverse effects than oral formulations

11Patient Discharge Instructions/pdi52

copy discharge instructions

›Diagnosis and injury explanation

›You have been diagnosed with a cuneiform fracture

›The cuneiform bones are three small bones in the middle of your foot

›This fracture can be treated without surgery if the bone is in good position

›Your fracture type and treatment plan

›Nondisplaced fracture: treated with boot or cast for 6 weeks

›Your orthopedic follow-up appointment details will be provided

›Activity and weight-bearing instructions

›Follow your provider's specific weight-bearing instructions

›You may be told: non-weight-bearing, partial weight-bearing, or weight-bearing as tolerated

›Use crutches or walker as instructed

›Keep foot elevated when resting

›Raise foot above heart level to reduce swelling

›Apply ice for 20 minutes at a time, several times daily

›Place cloth between ice pack and skin to prevent frostbite

›Boot or cast care

›Keep boot or cast dry

›Cover with plastic bag when bathing

›Do not remove the boot without being told to by your provider

›Do not put anything inside the cast

›Medications

›Take ibuprofen and acetaminophen as directed for pain

›Take ibuprofen with food to protect your stomach

›Do not exceed the maximum daily doses listed on packaging

›If opioids prescribed: take only as directed for severe pain

›Do not drive or operate machinery while taking opioids

›Avoid alcohol with opioid medications

12References/r33

Guidelines and key sources

›Silver S, Williams E, Plunkett ML. Common Foot Fractures. American Family Physician. 2024

›Primary grounding source for cuneiform fracture epidemiology, imaging, and management

›PMID 38393796

›Mabry LM, Patti TN, Ross MD, Bleakley CM, Gisselman AS. Isolated Medial Cuneiform Fractures: A Systematic Search and Qualitative Analysis of Case Studies. Journal of the American Podiatric Medical Association. 2021

›Systematic review: diagnostic delay, conservative outcomes, mean 65-day delay

›PMID 34478529

›Mehlhorn AT, Schmal H, Legrand MA, Sudkamp NP, Strohm PC. Classification and Outcome of Fracture-Dislocation of the Cuneiform Bones. Journal of Foot and Ankle Surgery. 2016

›Classification system: Mehlhorn Type 1/2/3 and Subtype A/B/C

›PMID 26860043

Imaging and decision tools

›Expert Panel on Musculoskeletal Imaging, Gorbachova T, Chang EY, et al. ACR Appropriateness Criteria: Acute Trauma to the Foot. Journal of the American College of Radiology. 2020

›CT and MRI indications for acute foot trauma

›Guidance on imaging selection based on clinical scenario

›Beckenkamp PR, Lin CC, Macaskill P, et al. Diagnostic Accuracy of the Ottawa Ankle and Midfoot Rules: A Systematic Review With Meta-Analysis. British Journal of Sports Medicine. 2017

›Ottawa rules sensitivity approximately 97% for midfoot fractures

›PMID 27884861

Analgesic and pain management references

›Nasr Isfahani M, Etesami H, Ahmadi O, Masoumi B. Comparing the Efficacy of Intravenous Morphine Versus Ibuprofen or the Combination of Ibuprofen and Acetaminophen in Patients With Closed Limb Fractures. BMC Emergency Medicine. 2024

›NSAID plus acetaminophen combination superior to opioids alone

›PMID 38273252

›Amaechi O, Huffman MM, Featherstone K. Pharmacologic Therapy for Acute Pain. American Family Physician. 2021

›AAFP guideline: topical NSAIDs first-line for non-low back musculoskeletal injuries

›PMID 34264611

›Optimizing the Treatment of Acute Pain in the Emergency Department. American College of Emergency Physicians. 2018

›ACEP policy: non-opioid agents first-line; sub-dissociative ketamine as adjunct

›Available at acep.org policy statements

Evidence & Review

Evidence & Review