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Traumatic Navicular Fracture
From WikiSM
Other Names
- Acute navicular fracture
- Tarsal Navicular Fractures
- Traumatic Navicular Fracture
Background
- This page refers to acute fractures of the Navicular
- Navicular Stress Fracture is discussed separately
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
- Navicular
- 'Keystone' of the arch of the foot[5]
- Articulates with the Cuneiforms (distal), Talus (proximal), and Cuboid (lateral)
Risk Factors
- Unknown
Differential Diagnosis
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Plantar Fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
- Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
- Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
- Toenail
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)
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
- Radiograph changes
- Evidence of healing in acute fractures seen at an average of 8.5 weeks[8]
Complications
- Persistent stiffness
- Pain
- Loss of hindfoot motion
- Post Traumatic Foot Arthritis
- Avascular Necrosis
- Nonunion
- Hindfoot Varus
See Also
- Internal
- External
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
References
- ↑ 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.
- ↑ Main BJ, Jowett RL. Injuries of the midtarsal joint. J Bone Joint Surg Br. 1975; 57:89-97.
- ↑ 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.
- ↑ 4.0 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.
- ↑ Eichenholtz SN, Levine DB. Fractures of the tarsal navicular bone. Clin Orthop Relat Res. 1964; 34:142-157.
- ↑ Rosenbaum AJ, Uhl RL, DiPreta JA. Acute fractures of the tarsal navicular. (2014) Orthopedics. 37 (8): 541-6.
- ↑ 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.
- ↑ 8.0 8.1 Golano P, Farinas O, Saenz I. The anatomy of the navicular and periarticular structures. Foot Ankle Clin. 2004; 9:1-23.