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Cuneiform Bones of the Foot

ossa cuneiformia pedis

The three cuneiform bones (medial, intermediate, and lateral) occupy the medial and middle columns of the midfoot between the navicular posteriorly and the first three metatarsal bases anteriorly. The medial cuneiform is the largest, articulating with the first metatarsal at the first TMT joint (the most stable); the intermediate cuneiform is the smallest and is recessed 8 mm posteriorly, creating the mortise into which the second metatarsal base locks — the anatomical basis of Lisfranc stability; the lateral cuneiform articulates with the third metatarsal.

Region: Foot & Ankle

Clinical Relevance

Clinical Notes

The intermediate cuneiform recess provides the anatomical basis for Lisfranc stability: the second metatarsal base keys into the intermediate cuneiform mortise and is bound to the medial cuneiform by the strong Lisfranc ligament. This Lisfranc anatomy means that cuneiform fractures, particularly avulsions of the medial cuneiform at the Lisfranc ligament attachment, indicate severe midfoot disruption. Medial cuneiform avulsion at the Lisfranc ligament attachment is the pathognomonic bony sign of Lisfranc injury.

Pathology

Common Injuries & Conditions

Medial Cuneiform Avulsion in Lisfranc Injury

Avulsion of the Lisfranc ligament from the medial cuneiform attachment (or second metatarsal base attachment) produces a small medial cuneiform fleck fracture that is pathognomonic of Lisfranc injury on weight-bearing radiograph; the avulsion confirms significant midfoot instability requiring ORIF or primary arthrodesis rather than conservative management.