Updated: 8/26/2019

Tarsal Navicular Fractures

Topic
Review Topic
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Questions
8
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Evidence
8
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Cases
4
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https://upload.orthobullets.com/topic/7033/images/sangeorzan type iii.jpg
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https://upload.orthobullets.com/topic/7033/images/mri-foot-sag- navicular stress fx - internet_moved.jpg
Introduction
  • 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  
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 IIII 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 avascular necrosis 
 

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Questions (8)
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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? Review Topic

QID: 4616
FIGURES:
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1

Observation alone

4%

(104/2600)

2

Cortisone injection in to the anterior tibial tendon sheath

1%

(22/2600)

3

Partial weight bearing in a boot

13%

(326/2600)

4

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

79%

(2048/2600)

5

Open reduction internal fixation of the fracture

3%

(87/2600)

L 2

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SUBMIT RESPONSE 4
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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? Review Topic

QID: 8734
FIGURES:
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1

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

5%

(6/126)

2

Open reduction and internal fixation

29%

(37/126)

3

Open reduction and internal fixation with autologous bone grafting

55%

(69/126)

4

No treatment

2%

(2/126)

5

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

6%

(7/126)

L 4

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

QID: 1420
FIGURES:
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1

Malunion

7%

(323/4767)

2

Non-union

81%

(3883/4767)

3

Infection

0%

(23/4767)

4

Longitudinal arch instability

10%

(482/4767)

5

Neurovascular injury

1%

(31/4767)

L 2

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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? Review Topic

QID: 172
FIGURES:
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1

Weight bearing as tolerated in a hard soled shoe

6%

(114/1900)

2

Non weight bearing cast immobilization

69%

(1311/1900)

3

Fragment excision and posterior tibial tendon advancement

2%

(34/1900)

4

Percutaneous screw fixation

16%

(306/1900)

5

Open reduction with autologous bone graft

7%

(129/1900)

L 2

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SUBMIT RESPONSE 2
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Topic COMMENTS (1)
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