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Symptomatic bipartite medial cuneiform after injury: a case report
Foot and Ankle Surgery 11 (2005) 55–58 www.elsevier.com/locate/fas
Case report
Symptomatic bipartite medial cuneiform after injury: a case report Q. Bismil*, P.A.L. Foster, B. Venkateswaran, J. Shanker Department of Orthopaedic Surgery, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire: BD9 6 RJ, UK Received 21 April 2004; revised 18 August 2004
Abstract We present the case of a 23 year old professional rugby player with bipartition of the medial cuneiform, which became symptomatic following a rugby injury. Both plain radiographs and MRI scanning failed to arrive at the correct diagnosis. CT scanning was, however, diagnostic. The gap in the cuneiform was injected with 40 mg of Depomedrone under CT guidance. The patient’s symptoms resolved sufficiently to enable him to begin training within a few weeks. He has returned to professional rugby, and has had no further problems with his foot. This case demonstrates that the injection of steroid into the gap in the cuneiform appears to be an effective treatment for symptomatic bipartite medial cuneiform. q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Bipartite medial cuneiform; Cuneiform; Bipartition of medial cuneiform
1. Introduction Symptomatic bipartition of the medial cuneiform is a rare condition. Earlier, this has been treated with surgery [1,3]. We present a case of bipartition of the medial cuneiform in a professional rugby player, which became symptomatic following a rugby injury. This was treated by injection of steroid into the gap in the cuneiform, under CT guidance.
2. Case report A 23 year old professional rugby player presented with pain in his left mid-foot, following a rugby injury. He had been lightly balanced on both feet, with the left in slight eversion and plantar flexion at the mid-foot level, when he darted to one side. He felt a sharp, severe pain, and was unable to continue playing. Ice packs were applied immediately and analgesics commenced. The following morning the foot was quite swollen. Over the next few weeks the swelling improved; the pain, however, did not. A few weeks later, the patient was assessed in the out-patient clinic. Clinically, the patient was thought to have suffered * Corresponding author. Tel.: C44 113 278 6563. E-mail address: [email protected] (Q. Bismil).
a mid-foot sprain. Plain AP, lateral and oblique radiographs were non-diagnostic (Figs. 1–3; right foot also shown for comparison). A Magnetic Resonance Imaging (MRI) scan was requested. This revealed abnormal signal within the medial cuneiform in particular, but also in the intermediate cuneiform and base of the second metatarsal (Figs. 4 and 5). The appearances were thought to be most consistent with ligamentous disruption between the medial and intermediate cuneiform, but the diagnoses of osteoid osteoma, low grade infection and fatigue fracture were also suggested. The patient was referred to the foot and ankle out-patient clinic, some 12 weeks after the injury. Despite rest and two steroid injections into the mid-foot, the patient was still experiencing symptoms. He had attempted to return to playing rugby 3 weeks previously, but had to come off the field after a few minutes on account of the pain. The patient denied pain at rest or on walking. However, he did complain of significant discomfort in the mid-foot area upon loading of the first metatarsal. The general examination was unremarkable. There was no deformity of the left foot. There was poorly localised tenderness in the first tarsometatarsal area. There was no abnormal mobility of the first tarso-metatarsal joint in the sagittal plane. However, application of an abduction strain in pronation caused significant discomfort in the first tarso-metatarsal joint and adjacent area of the mid-foot. In view of the clinical and
1268-7731/$ - see front matter q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2004.10.005
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Q. Bismil et al. / Foot and Ankle Surgery 11 (2005) 55–58
Fig. 4. Coronal MRI images of the medial cuneiform.
Fig. 1. AP and oblique radiographs of the left foot.
Fig. 2. Lateral radiograph of the left foot.
Fig. 3. AP and oblique radiographs of the right foot.
Fig. 5. Axial MRI images of the medial cuneiform.
Q. Bismil et al. / Foot and Ankle Surgery 11 (2005) 55–58
Fig. 6. CT images of the bipartite medial cuneiform.
Fig. 7. CT images of the bipartite medial cuneiform.
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Fig. 8. CT images of the bipartite medial cuneiform.
radiological signs, a Lisfranc injury was thought most likely. A computerised tomography (CT) scan was requested (Figs. 6–8). The CT scan revealed a bipartite medial cuneiform. The gap in the cuneiform was injected with 40 mg of Depomedrone under CT guidance. The patient’s symptoms resolved sufficiently to enable him to begin training within a few weeks. He has returned to professional rugby, and has had no further problems with his left foot.
This treatment may not be effective in all cases of this rare condition. However, our patient was cured after a single treatment, and was able to resume his sporting career. Therefore, we feel that CT-guided injection of steroid, which may avoid or at least delay the need for surgical intervention, should be considered as a first-line treatment for this condition.
Acknowledgements 3. Discussion Bipartitition of the medial cuneiform is a rare phenomenon; symptomatic cases are even more uncommon. A Medline search for ‘bipartite medial cuneiform’ reveals four previous reports in the literature [1–4]. This case highlights the diagnostic challenge that the condition presents to the clinician, and illustrates the value of CT in its management. Surgical treatment, both partial excision [1] and osteosynthesis [3], for symptomatic bipartite medial cuneiform has previously been described. In our case, we injected the gap in the cuneiform with Depomedrone under CT guidance, with good effect. The injection of steroid into the gap in the cuneiform appears to be an effective treatment for symptomatic bipartite medial cuneiform.
Dr S.S Karamuri, Consultant Radiologist, Dewsbury and District Hospital, West Yorkshire.
References [1] Chiodo CP, Parentis MA, Myerson MS. Symptomatic bipartite medial cuneiform in an adult athlete: a case report. Foot Ankle Int 2002;4: 348–51. [2] Dellacorte MP, Lin PJ, Grisafi PJ. Bilateral bipartite medial cuneiform. A case report. J Am Podiatr Med Assoc 1992;9:475–8. [3] Azurza K, Sakellariou A. Ostoesynthesis of a symptomatic bipartite medial cuneiform. Foot Ankle Int 2001;6:499–501. [4] O’Neal ML, Ganey TM, Ogden JA. Fracture of a bipartite medial cuneiform synchondrosis. Foot Ankle Int 1995;1:37–40.
Case report
Symptomatic bipartite medial cuneiform after injury: a case report Q. Bismil*, P.A.L. Foster, B. Venkateswaran, J. Shanker Department of Orthopaedic Surgery, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire: BD9 6 RJ, UK Received 21 April 2004; revised 18 August 2004
Abstract We present the case of a 23 year old professional rugby player with bipartition of the medial cuneiform, which became symptomatic following a rugby injury. Both plain radiographs and MRI scanning failed to arrive at the correct diagnosis. CT scanning was, however, diagnostic. The gap in the cuneiform was injected with 40 mg of Depomedrone under CT guidance. The patient’s symptoms resolved sufficiently to enable him to begin training within a few weeks. He has returned to professional rugby, and has had no further problems with his foot. This case demonstrates that the injection of steroid into the gap in the cuneiform appears to be an effective treatment for symptomatic bipartite medial cuneiform. q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Bipartite medial cuneiform; Cuneiform; Bipartition of medial cuneiform
1. Introduction Symptomatic bipartition of the medial cuneiform is a rare condition. Earlier, this has been treated with surgery [1,3]. We present a case of bipartition of the medial cuneiform in a professional rugby player, which became symptomatic following a rugby injury. This was treated by injection of steroid into the gap in the cuneiform, under CT guidance.
2. Case report A 23 year old professional rugby player presented with pain in his left mid-foot, following a rugby injury. He had been lightly balanced on both feet, with the left in slight eversion and plantar flexion at the mid-foot level, when he darted to one side. He felt a sharp, severe pain, and was unable to continue playing. Ice packs were applied immediately and analgesics commenced. The following morning the foot was quite swollen. Over the next few weeks the swelling improved; the pain, however, did not. A few weeks later, the patient was assessed in the out-patient clinic. Clinically, the patient was thought to have suffered * Corresponding author. Tel.: C44 113 278 6563. E-mail address: [email protected] (Q. Bismil).
a mid-foot sprain. Plain AP, lateral and oblique radiographs were non-diagnostic (Figs. 1–3; right foot also shown for comparison). A Magnetic Resonance Imaging (MRI) scan was requested. This revealed abnormal signal within the medial cuneiform in particular, but also in the intermediate cuneiform and base of the second metatarsal (Figs. 4 and 5). The appearances were thought to be most consistent with ligamentous disruption between the medial and intermediate cuneiform, but the diagnoses of osteoid osteoma, low grade infection and fatigue fracture were also suggested. The patient was referred to the foot and ankle out-patient clinic, some 12 weeks after the injury. Despite rest and two steroid injections into the mid-foot, the patient was still experiencing symptoms. He had attempted to return to playing rugby 3 weeks previously, but had to come off the field after a few minutes on account of the pain. The patient denied pain at rest or on walking. However, he did complain of significant discomfort in the mid-foot area upon loading of the first metatarsal. The general examination was unremarkable. There was no deformity of the left foot. There was poorly localised tenderness in the first tarsometatarsal area. There was no abnormal mobility of the first tarso-metatarsal joint in the sagittal plane. However, application of an abduction strain in pronation caused significant discomfort in the first tarso-metatarsal joint and adjacent area of the mid-foot. In view of the clinical and
1268-7731/$ - see front matter q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2004.10.005
56
Q. Bismil et al. / Foot and Ankle Surgery 11 (2005) 55–58
Fig. 4. Coronal MRI images of the medial cuneiform.
Fig. 1. AP and oblique radiographs of the left foot.
Fig. 2. Lateral radiograph of the left foot.
Fig. 3. AP and oblique radiographs of the right foot.
Fig. 5. Axial MRI images of the medial cuneiform.
Q. Bismil et al. / Foot and Ankle Surgery 11 (2005) 55–58
Fig. 6. CT images of the bipartite medial cuneiform.
Fig. 7. CT images of the bipartite medial cuneiform.
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Q. Bismil et al. / Foot and Ankle Surgery 11 (2005) 55–58
Fig. 8. CT images of the bipartite medial cuneiform.
radiological signs, a Lisfranc injury was thought most likely. A computerised tomography (CT) scan was requested (Figs. 6–8). The CT scan revealed a bipartite medial cuneiform. The gap in the cuneiform was injected with 40 mg of Depomedrone under CT guidance. The patient’s symptoms resolved sufficiently to enable him to begin training within a few weeks. He has returned to professional rugby, and has had no further problems with his left foot.
This treatment may not be effective in all cases of this rare condition. However, our patient was cured after a single treatment, and was able to resume his sporting career. Therefore, we feel that CT-guided injection of steroid, which may avoid or at least delay the need for surgical intervention, should be considered as a first-line treatment for this condition.
Acknowledgements 3. Discussion Bipartitition of the medial cuneiform is a rare phenomenon; symptomatic cases are even more uncommon. A Medline search for ‘bipartite medial cuneiform’ reveals four previous reports in the literature [1–4]. This case highlights the diagnostic challenge that the condition presents to the clinician, and illustrates the value of CT in its management. Surgical treatment, both partial excision [1] and osteosynthesis [3], for symptomatic bipartite medial cuneiform has previously been described. In our case, we injected the gap in the cuneiform with Depomedrone under CT guidance, with good effect. The injection of steroid into the gap in the cuneiform appears to be an effective treatment for symptomatic bipartite medial cuneiform.
Dr S.S Karamuri, Consultant Radiologist, Dewsbury and District Hospital, West Yorkshire.
References [1] Chiodo CP, Parentis MA, Myerson MS. Symptomatic bipartite medial cuneiform in an adult athlete: a case report. Foot Ankle Int 2002;4: 348–51. [2] Dellacorte MP, Lin PJ, Grisafi PJ. Bilateral bipartite medial cuneiform. A case report. J Am Podiatr Med Assoc 1992;9:475–8. [3] Azurza K, Sakellariou A. Ostoesynthesis of a symptomatic bipartite medial cuneiform. Foot Ankle Int 2001;6:499–501. [4] O’Neal ML, Ganey TM, Ogden JA. Fracture of a bipartite medial cuneiform synchondrosis. Foot Ankle Int 1995;1:37–40.