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Updated: Jun 7 2021

Tarsal Navicular Fractures

Images type ii.jpg navicular stress fx - internet_moved.jpg navicular stress fx - internet_moved.jpg type iii.jpg
  • 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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