Updated: 6/7/2021

Tarsal Navicular Fractures

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Cases
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  • Summary
    • Tarsal Navicular Fractures are rare fractures of the midfoot that may occur due to trauma or due to repetitive microstress.
    • Diagnosis can be made with plain radiographs of the foot.
    • Treatment is generally nonoperative with cast immobilization and non weight-bearing for the majority of fractures. Surgical management is indicated for nonunions, significantly displaced fractures, and for elite athletes. 
  • Etiology
    • Navicular fractures can be
      • traumatic
        • navicular avulsion fractures
          • mechanism is plantarflexion or eversion/inversion
          • can involve talonavicular or naviculocuneiform ligaments
        • navicular tuberosity fractures
          • mechanism is eversion with simultaneous contraction of PTT
          • may represent an acute widening/diastasis of an accessory navicular
        • navicular body fractures
          • mechanism is axial loading
      • stress fracture
        • mechanism of injury is usually due to chronic overuse
        • often seen in athletes running on hard surfaces
        • also common in baseball players
        • considered a high risk injury due to risk of AVN
        • most common complications include delayed union and non-union
    • Spontaneous navicular AVN (Mueller-Weiss syndrome)
      • Spontaenous navicular AVN is a rare disease that and can be seen in middle aged adults with chronic midfoot pain
  • Anatomy
    • Articulations
      • navicular bone articulates with
        • cuneiforms
        • cuboid
        • calcaneus
        • talus
    • Biomechanics
      • navicular bone and its articulations play an important role in inversion and eversion biomechanics and motion
  • Classification
    • Sangeorzan Classification of Navicular Body Fractures
      (based on plane of fracture and degree of comminution)
      Type I
      • Transverse fracture of dorsal fragment that involves < 50% of bone.
      • No associated deformity
      Type II
      • Oblique fracture, usually from dorsal-lateral to plantar-medial.
      • May have forefoot ADduction deformity.
      Type III
      • Central or lateral comminution.
      • ABduction deformity.
  • Presentation
    • Symptoms
      • vague midfoot pain and swelling
    • Physical exam
      • midfoot swelling
      • tenderness to palpation of midfoot
      • usually full ROM of ankle and subtalar joint
  • Imaging
    • Radiographs
      • may be difficult to see and are often missed
      • recommended views
        • AP
        • lateral
        • oblique 45 degree radiograph
          • best to visualize tuberosity fractures
    • CT
      • more sensitive to identify fracture than radiographs
    • MRI
      • will show signal intensity on T2 image due to inflammation
  • Treatment of Stress Fractures
    • Nonoperative
      • cast immobilization with no weight bearing
        • indications
          • any navicular stress fracture, regardless of type, can be initially treated with cast immobilization and nonweight bearing for 6-8 weeks with high rates of success
    • Operative
      • open reduction and internal fixation
        • indications
          • high level athletes
          • nonunion of navicular stress fracture
          • failure of cast immobilization and non weight bearing
  • Treatment of Traumatic Fractures
    • Nonoperative
      • cast immobilization with no weight bearing
        • indications
          • acute avulsion fractures
          • most tuberosity fractures
          • minimally displaced Type I and II navicular body fractures
    • Operative
      • fragment excision
        • indications
          • avulsion fractures that failed to improve with nonoperative modalities
          • tuberosity fractures that went on to symptomatic nonunion
      • open reduction and internal fixation
        • indications
          • avulsion fractures involving > 25% of articular surface
          • tuberosity fractures with > 5mm diastasis or large intra-articular fragment
          • displaced or intra-articular Type I and II navicular body fractures
        • technique
          • medial approach
            • used for Type I and II navicular body fractures
      • ORIF followed by external fixation vs. primary fusion
        • indications
          • Type III navicular body fractures
          • navicular avascular necrosis
        • technique
          • must maintain lateral column length
          • fusion of talonavicular and naviculocuneiform joints in navicular avascular necrosis

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(SBQ12FA.26) A 45-year-old man presents to the orthopaedic clinic complaining of several weeks of increasing midfoot pain during and after his daily run that he recently resumed after a 2-week vacation. He is found on imaging to have a navicular stress fracture. What is the most appropriate initial immobilization and weight-bearing status for this patient?

QID: 3833
1

Hard-sole shoe and non-weight bearing

5%

(194/3563)

2

Hard-sole shoe and partial weight bearing

5%

(173/3563)

3

Walking boot and partial weight bearing

12%

(442/3563)

4

Short leg cast and non-weight bearing

73%

(2614/3563)

5

Short leg cast and partial-weight bearing

3%

(111/3563)

L 2 C

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(OBQ12.256) A 21-year-old recreational baseball player presents for evaluation of anterior ankle pain that has been persistent for the past 6-8 weeks. On physical exam he is tender over the midfoot, but has full strength with dorsiflexion, plantarflexion and inversion. His radiographs are read as normal; radiographs are shown in Figure A. Representative MRI sequences are shown Figures B and C. What is the most appropriate treatment for this patient?

QID: 4616
FIGURES:
1

Observation alone

4%

(121/3055)

2

Cortisone injection in to the anterior tibial tendon sheath

1%

(24/3055)

3

Partial weight bearing in a boot

13%

(399/3055)

4

Non-weightbearing in a cast for planned 6-8 weeks

78%

(2390/3055)

5

Open reduction internal fixation of the fracture

3%

(103/3055)

L 2 B

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(SAE07SM.72) An 18-year-old gymnast has had a 1-year history of foot pain. Examination reveals medial midfoot tenderness without swelling. Non-weight-bearing in a cast for 6 weeks has failed to provide relief. An axial CT scan of the midfoot is shown in Figure 20. What is the optimal treatment for this condition?

QID: 8734
FIGURES:
1

Partial weight bearing in a walking cast for an additional 6 weeks

3%

(13/457)

2

Open reduction and internal fixation

26%

(117/457)

3

Open reduction and internal fixation with autologous bone grafting

62%

(282/457)

4

No treatment

1%

(3/457)

5

Non-weight-bearing in a cast for an additional 6 weeks

8%

(37/457)

L 4 E

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(SBQ07SM.35) What is the most common complication associated with the injury seen in Figure A?

QID: 1420
FIGURES:
1

Malunion

7%

(353/5291)

2

Non-union

81%

(4295/5291)

3

Infection

1%

(28/5291)

4

Longitudinal arch instability

10%

(549/5291)

5

Neurovascular injury

1%

(36/5291)

L 2 C

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(OBQ06.61) A 24-year-old female who is training for her first marathon presents with six weeks of increasing foot pain. An AP radiograph and representative axial cut of her CT scan of her injury are seen in figures A and B. Management should consist of which of the following?

QID: 172
FIGURES:
1

Weight bearing as tolerated in a hard soled shoe

6%

(135/2338)

2

Non weight bearing cast immobilization

66%

(1546/2338)

3

Fragment excision and posterior tibial tendon advancement

2%

(44/2338)

4

Percutaneous screw fixation

18%

(411/2338)

5

Open reduction with autologous bone graft

8%

(195/2338)

L 2 D

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