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Observation alone
4%
140/3605
Cortisone injection in to the anterior tibial tendon sheath
1%
33/3605
Partial weight bearing in a boot
13%
462/3605
Non-weightbearing in a cast for planned 6-8 weeks
79%
2831/3605
Open reduction internal fixation of the fracture
3%
118/3605
Select Answer to see Preferred Response
Based on the clinical history and imaging shown, the patient has a navicular stress fracture of the foot. The most appropriate treatment for this patient is to place the patient into a non-weightbearing cast with outpatient follow up in 6-8 weeks. Tarsal navicular stress fractures are often the result of overuse, particularly while running on hard surfaces. They are common in baseball players. Patients often present with vague, midfoot pain, swelling and localized tenderness. Immobilization and non-weight bearing can be used to treat most navicular stress fractures, even in high level athletes. Fowler et al. review the treatment options for stress fracture for the tarsal navicular. They indicate that diagnosis can be difficult because of the high false negative rate of standard radiographs. While surgical intervention has become increasingly popular, they recommend that initial management should be conservative non-weight bearing for these injuries. Torg et al. discuss a meta-analysis of the efficacy of surgical versus conservative management of tarsal navicular stress fractures. They found no statistically significant difference between conservative (non-weight bearing) and surgical intervention in terms of overall outcome; however there was a trend favoring use of conservative management. They recommend immobilization with non-weight bearing as the standard of care for tarsal navicular stress fractures. Figure A shows an AP and oblique radiograph of a right foot. While hard to discern on the AP radiograph, a step-off is visualized at the dorsal and proximal aspect of the navicular. Some mild comminution is seen as well. Figures B and C show representative sequences from a T2 weighted MRI of the foot. The minimally displaced injury is appreciated through the axial and sagittal sequences seen. Incorrect Answers Answer 1: Observation is not indicated as treatment for this patient Answer 2: This patient does not have evidence of anterior tibial tendinitis Answer 3: Torg et al. have reported worse outcomes when partial weight bearing was used Answer 5: Outcomes do not support use of operative intervention as the first line of treatment, even in high level athletes.
4.2
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