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X-raying a 42 Y/O M for Calcaneal-Cuboid pain and saw this, a bipartite Cuneiform.
"There have been only 3 reports in the literature citing bipartite medial cuneiform in a living patient as an incidental finding."
Can we make it 4?
Anyone with any experience with these?
I think in this case it's just an coincidental finding.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Hi Suresh:
I'm out of town and don't have access to the original right now,
but;
the line of demarkation runs proximal to distal. If you look at the med cuneiform you will see a line running through the middle from the middle of the distal navicular articular surface to the middle of the articular surface at the first metabase. This gives you what amounts to dorsal and plantar halves.
Hope that helps.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Last edited by drsarbes : 6th February 2009 at 07:48 PM.
Reason: spelling
I've seen and treated a few symptomatic bipartite cuneiforms. Most that I've seen have been incidental findings though. Good catch, I think most people wouldn't recognize it for what it is.
Hi Efs:
THis was an old post.
Looking at your post op xray.....what kind of symptoms did your patient have?
bilateral?
Traumatic?
I'd like to hear about the procedure.
Thanks
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Interesting topic to me. It's something unusual, but by chance I've seen it a few times. The one in the xray presented with chronic medial midfoot pain and history of remote injury (MVA Rollover). Initially treated conservatively without relief. He then had a dorsal met-cuneiform exostectomy which helped for about 5-6 months. At that point he was offered fusion of the bipartite medial cuneiform. About 5 months after surgery he was able to return to running and other activities.
A medial approach was taken in surgery, directly over the bipartition. On opening it there was cartilage on both surfaces, which was removed with a rongeour and curettes. Fenestrated both surfaces, and placed the screws percutaneously from dorsal to plantar.
I saw another case which was initially treated as a Lisfranc's injury, with conservative treatment. He also underwent fusion of cuneiform, but also had a screw placed across the cuneiform to the 2nd met base.
Last surgical one was a baseball injury in which the bipartite cuneiform was displaced, so did ORIF with fusion of the bipartition.
Recently I saw another symptomatic bipartite cunieform, but improved with steroid injection done under fluoroscopy.
I think I've seen enough of them that it should be a publishable article, but it's taking me longer to write it than it ought to. BTW in our digital xray system, I was able to find ~ 40 others, incidental findings. I think it may be more frequent than we think, just overlooked. I have a young active patient population which may be why I've seen it, and I look for it. I was recently looking at my materials again, and did a search which is how I found the one you mentioned.
Thanks.
Eric
Last edited by efs : 20th September 2009 at 08:26 AM.
Reason: add
Thanks for the info Eric: Interesting stuff. I remember seeing 3 in 30 years, non symptomatic.
Good luck on your paper, if you need my case just for "numbers" let me know I'll send the vital stats to you.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
thanks for showing this case. I have seen few similar cases last year. You can identify the bipartite cuneiform on sagittal images showing an E-sign as actually seen in the x-ray of your case. See Elias I et al, bipartite cuneiform in Journal of Medical Case Reports 2008. Also, all cases we saw in clinic had symptomatic midfoot and the bipartite was unexpected and an incidental finding.
We report the case of an 11-year-old boy who had sustained a soccer injury to his mid-foot. Plain radiography did not reveal any fracture to account for the severity of his symptoms or his inability to bear weight. Magnetic resonance imaging was undertaken and demonstrated the medial cuneiform to be a bipartite bone consisting of 2 ossicles connected by a synchondrosis. No acute fracture or diastasis of the bipartite bone was demonstrated; however, significant bone marrow edema was noted, corresponding to the site of the injury and his clinical point bony tenderness. This anatomic variant should be considered as a rare differential diagnosis in the skeletally immature foot. The injury was treated nonoperatively with a non-weightbearing cast and pneumatic walker immobilization, with successful resolution of his symptoms and a return to sports activity by 4 months after injury.
Interesting: BiPartite Cuneiform
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