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Traumatic Navicular Fracture

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Other Names

  • Acute navicular fracture
  • Tarsal Navicular Fractures
  • Traumatic Navicular Fracture

Background

History

Epidemiology

  • Most frequently injured tarsal bone (need citation)

Pathophysiology

Mechanism

  • Most commonly associated with MVC
  • Avulsion fracture
    • About 50% of them are avulsion fractures[1]
    • Can be due to disruption of a variety of soft tissue structures
  • Body fractures
    • Direct (crush)
    • Indirect (axial load)
      • Main et al: longitudinal compression of the plantarflexed foot causes impaction of the cuneiforms into the navicular[2]
      • Nyska et al: cuneiforms are compressed backward, causing the navicular to be crushed bytalar head with ankle in plantarflexion[3]
      • Others: it is a combination of plantarflexion and abduction at the midtarsus
  • Tuberosity fractures
    • Due to eversion with simultaneous contraction of Posterior Tibialis Tendon
    • May represent an acute widening/diastasis of an accessory navicular

Associated Conditions

  • Ipsilateral foot injuries
    • One study identified a 62% incidence of concurrent midfoot and hindfoot injuries[4]

Pathoanatomy

Risk Factors

  • Unknown

Differential Diagnosis

Clinical Features

  • History
    • Acute injuries should have a traumatic etiology
    • Avulsion and tuberosity fractures usually have a low-energy mechanism
    • Body fractures usually have a high energy mechanism
    • Patient will endorse pain, swelling over the midfoot
    • Trouble weight bearing
  • Physical Exam: Physical Exam Foot
    • Swelling may be noted over dorsomedial midfoot
    • Tenderness to navicular
    • Limited weight bearing, pain with push-off during gait
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Initial imaging modality of choice
    • Not very sensitive for navicular fracture
    • Lateral, oblique views provide best detail (need citation)
  • Acute findings
    • Avulsion fracture demonstrate a fleck of cortical bone
  • Accessory navicular bone
    • May be seen and can present as a fracture
    • May also be confused as a tuberosity fracture
    • Compare to other foot as needed

CT

  • Utility
    • More sensitive than radiographs for identifying navicular fractures
    • Useful to assess extent of fracture, degree of comminution

MRI

  • Utility
    • Most sensitive for identifying stress fractures[6]
    • Not generally indicated for acute fractures
  • Findings
    • T2 hyperintensity over fracture site indicating bone edema

Classification

Sangeorzan Classification

  • Used to assess severity of fracture, determine management[7]
  • Type I
    • Fracture line is in the coronal plane
    • Dorsal fragment consisting of less than 50% of the body
    • No angulation of the forefoot
    • No disruption of the alignment of the foot’s medial border
  • Type II
    • Fracture line is dorsal-lateral to plantar-medial
    • Major fragment and forefoot is medially displaced
    • Naviculocuneiform joint usually remains intact
    • Dorsal talonavicular ligament is often involved
  • Type III
    • Comminuted fracture in the sagittal plane
    • Medial border of the foot is usually disrupted at the naviculocuneiform joint
    • Forefoot is displaced laterally
    • Some involvement of the calcaneocuboid joint as well[8]

Management

Nonoperative

  • Indications
    • Avulsion fractures
    • Nondisplaced body fractures
  • Avulsion fracture
    • Immobilization: Supportive Shoe, Cast Boot, Short Leg Cast
    • If limited swelling and soft tissue injury, can weight bear as tolerated
    • If more serious swelling, pain or ligament injury, non weight bearing for 6 weeks
  • Body fracture
    • Protected weight bearing in a Short Leg Cast
    • Radiographs every 2-4 weeks to assess for displacement

Operative

  • Indications<ref>Banerjee R, Nickisch F, Easley M, DiGiovanni CW. Foot injuries. In Browner B, Jupiter J, Levine A, Trafton P, Krettek C, eds. Skeletal Trauma. Philadelphia, PA: WB Saunders; 2008:2671-2672./ref>
    • Displacement or joint incongruity greater than 1 mm
    • Medial column shortening greater than 2 to 3 mm
    • Resultant subluxation or dislocation
    • Lateral column involvement
    • Open wounds
    • Compartment syndrome
    • Gross instability
    • Skin tenting
    • Irreducible dislocations
  • Technique
    • Open reduction, internal fixation (ORIF)

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Surgical outcomes
    • Fracture pattern, quality of reduction correlate with outcome[4]
    • Sangeorzan et al: satisfactory reduction obtained in type-1 fractures (100%), type- 2 (67%), type-3 (50%)[7]
    • Evans found no evidence of nonunion, loss of reduction, deep infection with miniplate fixation[4]
  • Radiograph changes
    • Evidence of healing in acute fractures seen at an average of 8.5 weeks[8]

Complications

See Also

References

  1. ↑ Pinney S, Sangeorzan BJ. Fractures of the tarsal bones. In: Sangeorzan BJ, ed. The Traumatized Foot. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2001:41-53.
  2. ↑ Main BJ, Jowett RL. Injuries of the midtarsal joint. J Bone Joint Surg Br. 1975; 57:89-97.
  3. ↑ Nyska M, Marguiles J, Barbarawi M, Mutchler W, Dekel S, Segal D. Fractures of the body of the tarsal navicular bone. J Trauma. 1989; 29:1448-1451.
  4. ↑ 4.0 4.1 4.2 Evans J, Beingnessner D, Agel J, Benirschke SK. Minifragment plate fixation of highenergy navicular body fractures. Foot Ankle Int. 2011; 32:485.
  5. ↑ Eichenholtz SN, Levine DB. Fractures of the tarsal navicular bone. Clin Orthop Relat Res. 1964; 34:142-157.
  6. ↑ Rosenbaum AJ, Uhl RL, DiPreta JA. Acute fractures of the tarsal navicular. (2014) Orthopedics. 37 (8): 541-6.
  7. ↑ 7.0 7.1 Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen ST. Displaced intra-articular fractures of the tarsal navicular. (1989) The Journal of bone and joint surgery. American volume. 71 (10): 1504-10.
  8. ↑ 8.0 8.1 Golano P, Farinas O, Saenz I. The anatomy of the navicular and periarticular structures. Foot Ankle Clin. 2004; 9:1-23.
Created by:
John Kiel on 28 September 2021 17:07:42
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Last edited:
4 October 2022 12:34:43
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