Nutcracker Fracture – Causes, Symptoms, Diagnosis, Treatment

A nutcracker fracture of the cuboid refers to a cuboid bone fracture with associated navicular traumatic avulsion fracture due to compression between the bases of the 4th and 5th metatarsals and calcaneus bone. The injury usually occurs secondary to the trauma and causes abduction of the forefoot.  It results from forced plantar flexion and abduction, crushing the cuboid among the calcaneus and fourth and fifth metatarsals bone. Old nutcracker fracture of the cuboid bone with shortening of the lateral column changes the weight-bearing position of the foot and results in long term pain and/or instability

The anatomy of the cuboid is the most complex structure, with six articular surfaces involved altogether in the intricate movements of the midfoot and hindfoot. It’s an even more uncommon fracture or injury for a cuboid fracture to occur in isolation, without other associated injuries to the foot. The mechanism of injury has been described as forced abduction of the midfoot or forefoot, usually together with axial forces, leading to simultaneous compression of the lateral column and tensile stretching of the medial column.

Causes

  • The repetitive impact – to the metatarsals bone with weight-bearing exercises cause microfractures, which consolidate to stress fractures.
  • The most common location of metatarsal stress fractures – anatomically second metatarsal neck as it is less flexible and prone to torsional forces given its strong ligamentous attachment to the 1 and 2 cuneiforms and the second metatarsal bone is the longest of the metatarsals, subjected to the most force.
  • Heavy impact – The force of a jump or fall down from height can result in a broken ankle. It can happen in metatarsal bone fractures even if you jump from a low height.
  • Missteps – You can cause a fracture of the ankle if you put your foot down awkwardly abnormally. Your ankle might twist or roll your foot joint to the side as you put weight on it. It can also happen in stare up or stare down unawkwardly.
  • Sports – High-impact sports such as football cricket, hockey, volley boll involve intense movements that place stress on the joints, including the ankle bone fracture examples of high-impact sports include, cricket, racer of the bike, soccer, football, Horseback riding, Hockey, Skiing Snowboarding In-line skating, Jumping on a trampoline and basketball.
  • Car collisions – The sudden, heavy impact of a car accident, bike accident can cause metatarsal bone fractures. Often, these types of injuries need surgical repair. The crushing types of injuries common in car accidents may cause breaks that require surgical repair.
  • Falls from height – Tripping, and falling when walking on uneven surfaces can break bones in your ankles and metatarsal bone, phalanges fractures, as can landing on your feet after jumping down from just a slight height.
  • Missteps – Sometimes just putting your foot down the wrong way can result in a twisting injury that can cause a broken bone. Fracture also occurs when stairs up or stairs down, especially older people.
  • Unconsciously Toilet Use – It is a very common and day by day increasing incidence of fracture of the ankle joint, foot bone, metatarsal bones, tarsal bone, phalanges, especially high comodo using time and lower limb fractures.
  • High hell Use – It is the most common cause of fracture in the ankle, foot, lower limb fracture, especially for women, abnormal arch, foot angle, the lake of the flat foot, abnormal sole of your footwear, muscle, tendon, cartilage, ligament weakness in the knee, ankle joints.
  • On a battlefield – with the increasing of technology, nuclear weapons, one country is involved in the war from one country to another country. On the battlefield, millions of armies and general people are falling in injury that is gradually causing ankle, foot, metatarsal, tarsal bone fractures.
  • Have osteoporosis –  a disease of your bone that weakens your bones gradually due to inadequate intake of calcium or vitamin D.
  • Weak low muscle mass or poor muscle strength – lack agility or older age muscle strength, mass, power, endurance become weak, and poor balance conditions make you more likely to fall and cause a fracture.
  • Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing,  Skiing Snowboarding, in-line skating, Jumping, playing lead to fracture of the bone in the lower limb.

Symptoms

Symptoms of bone fractures include

  • Intense pain, swelling, tenderness, limited range of motion is the first
  • Pain with or after normal activity
  • Pain that goes away when resting time and then returns when standing, walking, or during activity
  • Pinpoint pain at the site of the fracture when touched
  • Swelling but no bruising may be present if it becomes microtrauma
  • Bruising or discoloration that extends to nearby parts of the foot bones.
  • Pain with walking and weight-bearing
  • Swelling in the heel area
  • Pain may decrease with rest but increases again with activity.
  • Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
  • Significant swelling may occur along the length of the leg or may be more localized.
  • Blisters may occur over the fracture site after some days.
  • Bruising that develops soon after the injury time.
  • Inability to walk; it is possible to walk with less severe breaks, and fractures so never rely on walking as a test of whether or not a bone has been fractured.
  • Change in the color and appearance of the ankle will look different from the other ankle.
  • Bone protruding fracture through the skin is a sign that immediate emergency care is needed. Fractures that pierce the skin require attention because they can lead to severe infection and take a prolonged time to recover.
  • This pain may occur or feel in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with pain or pain of worsening quality or duration over time.

Diagnosis

History

Your doctor in the emergency department may ask the following questions

  • How – How was the fracture created, and, if chronic, why is it still open? (underlying etiology)
  • When – How long has this fracture been present? (e.g., chronic less than 1 month or acute, more than 6 months)
  • What – What anatomy and structure do it involve? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves). What comorbidities, economic or social factors do the patient have which might affect their ability to heal the fracture?
  • Where – Where on the body parts is it located? Is it in an area that is difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery?
  • What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit,  anabolic steroid uses for athletes, etc?

Physical Examination

Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling. If the fracture is in the dept of a joint, the joint motion, normal movement will aggravate the pain.

  • Inspection – Your doctor also check superficial tissue, skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full-thickness also extends through the dermis and into the adipose tissues or full-thickness extends through the dermis, and adipose exposes muscle, bone, evaluate and measure the depth, length, and width of the fracture. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached and evaluate for signs and symptoms of infect warm, pain, delayed healing.
  • Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture. Condition of the surrounding skin and soft tissue, quality of vascular perfusion and pulses, and the integrity of nerve function.
  • Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means only that the muscles and tendons work properly, and does not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is not correct. The jerk test and manual test are also performed to investigate the motor function.
  • Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side. Sensory 2-point discrimination
  • Range of motion – A range of motion examination of the fracture associate joint and it’s surrounding joint may be helpful in assessing the muscle, tendon, ligament, cartilage stability. Active assisted, actively resisted exercises are performed around the injured area joint.
  • Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to heart and it is pressed the toe turns white (capillary refill).

Lab Test

Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.

Imaging Test

X-ray

X-rays are generally used to identify and characterize blockish injuries. A nutcracker fracture of the cuboid is stylishly imaged on the oblique view of an-ray. This view reveals the connections between the blockish bone and the 4th and 5th metatarsal bones located in the front ( anterior side) of the cuboid. The oblique view may also be used to identify the length of the side part of the bottom, which can be anticipated to change when the blockish bone is crushed.

CT and MRI

Advanced imaging similar to a Reckoned Tomography (CT) or Glamorous Resonance Imaging (MRI) can be used to more understand the fracture pattern involving the blockish and identify any associated injury to other bones, ligaments, or soft towels.

Treatment

Initial Treatment Includes

  • Get medical help immediately – If you fall on an outstretched leg, play cricket gets into a car accident, or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in your leg, foot, ankle joint, and part of your leg closer to the base of your leg. If the accident is major you keep your leg at the same heart position and then clean and treat any wounds on the skin of the injured leg.
  • Aggressive wound care – It is very important for patients to reach a safe position with the proper ventilation needed for contaminated wounds. Injured are clear with disinfectant material
  • ICE and elevation – It help for prevention swelling, edema
  • Rest – Sometimes rest is all, that is needed to treat a traumatic fracture of the foot, ankle, tarsal and metatarsal fracture. Sometimes rest is the only treatment needed to eradicate healing of a stress or traumatic fracture of a metatarsal bone fracture.
  • Compression – a bandage will limit swelling, edema, and help to rest the joint. A tubular compression bandage is frequently used but should be removed at night by easing it off gradually. Put it on again before you are from out of bed in the morning. Mild to moderate pressure that is not too uncomfortable or too tight, and does not stop blood flow, is ideal. Depending on the amount of swelling. pain, edema you may be advised to remove the bandage for good after 48 hours.
  • Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot upright on a chair or pillow to at least hip level when you are sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in fractures.
  • Splinting – The toe may be fitted with a splint to keep it in a fixed position.
  • Rigid or stiff-soled shoes – Wearing strong stiff-soled shoes to protect the toe and help keep it properly positioned. Use of a postoperative splint, shoe, or boot walker is also helpful.
  • Avoid the offending activity – Because fractures result from repetitive stress, the trauma it is important to avoid the activity that led to the fracture more seriously. Crutches or a wheelchair, or other types of supporting splint are sometimes required to offload weight from the foot to give it time to heal.
  • Immobilization, casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  • Casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  • Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is important for healing. This may mean using crutches or even a wheelchair.

Do no HARM for 72 hours after injury

  • Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
  • Alcohol –  stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
  • Running and movement – Running and walking may cause further damage, and causes healing delay.
  • Massage – A massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

  • Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Surgery

Surgical treatment is reserved for compressed and intraarticular fractures and aims to revive the articular congruency and length of the bone. Bone grafting is usually required as cancellous bone impaction may be a common finding with these fractures.19 The fixation is often achieved with the utilization of K-wires, 2.7 mm or 3.5 mm interfragmentary screws alongside a mini-plate, or the utilization of an external fixator.13,19,20 The incision is at the lateral border of the extensor Brevis muscle which can allow an honest exposure of the dorsolateral aspect of the bone. A distractor or external fixator is often wont to restore the length of the lateral column (proximal pin on the calcaneus and distal pin at the 5th or/and 4th metatarsal).21 The external fixator is often left in situ for 6–8 weeks to facilitate healing and counteract the compressive forces exerted on the bone. In cases of cuboid subluxation or dislocation, the reduction is often achieved with the utilization of a threaded K-wire alongside the utilization of an external fixator. The reduction is often maintained with either K-wires or screws running across the calcaneus and lateral cuneiform.

References