Edit concept Question Editor Create issue ticket

Navicular Fracture

Navicular (foot) Fracture

The navicular bone maintains the foot’s medial longitudinal arch and is a key component of hind-foot motion. Athletes that are prone to high-impact injuries, such as the runners, sprinters, jumpers, hurdlers, and gymnasts, have increased susceptibility for navicular fracture. Common navicular injuries include stress fractures, avulsion or traumatic separation of the accessory navicular, and partial or complete tears of the attachment of the plantar calcaneonavicular ligament.


Presentation

Patients often present with unilateral dorsal foot pain accompanied by swelling. The pain may be of insidious onset or it may follow an injury. It is often described as aching or tenderness at the navicular region. Patients may also have limited weight bearing ability. With continued activity, the onset of pain occurs sooner during the activity and lasts longer after cessation of activity [1] [2] [3] [4]. Swelling is often present at the dorsomedial midfoot; it may be present diffusely as well. The clinician should bear in mind that foot injuries, in addition to navicular fracture, may be present [5].

Wrist Arthritis
  • Figure 1: Scaphoid non-union with Wrist arthritis Figure 1: Scaphoid non-union Figure 2 Figure 3 Figure 4: CT scan showing a scaphoid fracture Figure 5: MRI showing an occult fracture fracture Figure 6[centraljerseyhand.com]
  • There are many types of procedures that can be performed for wrist arthritis.[orthoinfo.aaos.org]

Workup

Workup begins with a history and physical exam. Physical exam consists of a comparison of the arch between the affected and the uninvolved foot. Asymmetry (e.g., loss of longitudinal height of the arch during full weight-bearing) may reveal injuries such as rupture of the navicular ligament or the posterior tibialis tendon. Palpation of the medial arch often elicits pain at the proximal dorsal portion of the navicular (the "N spot"), directly over the navicular body in the superior medial arch alongside the anterior tibialis tendon [6]. This is a key physical finding and highly suggestive of a navicular fracture [7]. During the physical exam, passive eversion, active inversion, and/or hopping while standing on tip-toes will cause pain. In addition to a musculoskeletal exam, a neurovascular examination should be performed. Compartment syndrome should be considered when there is a significant degree of swelling.

X-rays are the most commonly used imaging modality for diagnosis; a computed tomography (CT) scan and/or magnetic resonance imaging (MRI) are more sensitive imaging modalities and may reveal subtle injuries. If a navicular fracture is suspected based on the patient’s history and physical exam findings, and X-rays do not demonstrate a fracture, a CT or MRI should be performed for a more thorough evaluation.

X-rays of both feet are recommended (i.e., the affected foot as well as the opposite foot for purposes of comparison). Foot X-rays consisting of anteroposterior (AP), lateral, and oblique views should be obtained. An external oblique view permits optimal imaging of the navicular tuberosity [10]. Stress views can help rule out acute ligamentous injury. In patients with high-energy injuries, ankle X-rays can help identify any concomitant injuries. X-rays of the contralateral foot may be obtained for comparison of the accessory navicular [8]. Avulsion fractures are characterized by a fleck of cortical bone. Tuberosity fractures should be differentiated from the injury of the accessory navicular [9].

CT scan permits identification of any subtle injuries and/or intra-articular fracture [10]. MRI may be used to identify injuries to the posterior tibial tendon, spring ligament, and/or accessory navicular [11].

Treatment

  • Only few case reports exist, which describe the probable mechanism of injury and optimal treatment. Of the few case reports, only one describes closed reduction with external fixator and percutaneous fixation as the treatment modality.[ncbi.nlm.nih.gov]
  • Treatment was 49/90 (55%) NOT and 41/90 (45.6%) ORIF. 11/41 (30%) ORIF required bone grafting.[ncbi.nlm.nih.gov]
  • This article reviews the posttraumatic sequelae that can be seen after navicular fracture and provides an overview of the treatment principles and alternatives that are available.[ncbi.nlm.nih.gov]
  • Several authors have confirmed the efficacy of this treatment protocol.5,12,15 Even in patients who have failed treatment in a weightbearing cast, the use of a non-weightbearing cast treatment compares favorably with surgical treatment.12 Khan and colleagues[podiatrytoday.com]

Prognosis

  • Google Scholar Simon LC, Schulz AP, Faschingbaker M, Morlock M, Jurgens C: Basketball foot-long-time prognosis after peritalar dislocation. Sportverlatz Sportschaden. 2008, 22: 31-37. 10.1055/s-2008-1027208.[casesjournal.biomedcentral.com]
  • Prognosis of a navicular stress fracture With appropriate physiotherapy management, most patients with a stress fracture of the navicular can make a full recovery (return to sport or full activities) in a period of 3 – 9 months.[physioadvisor.com.au]
  • Treatment and prognosis Acute pain can be managed can be achieved by corticosteroid injection and immobilization of the foot for 2-3 weeks. For refractory cases, surgical management can be considered.[radiopaedia.org]
  • […] types as follows: type I is a coronal fracture with no dislocation, type II is a dorsolateral to plantomedial fracture with medial forefoot displacement, and type III is a comminuted fracture with lateral forefoot displacement and carries the worst prognosis[eoj.eg.net]

Etiology

  • […] subsequent encounter for fracture with delayed healing K- subsequent encounter for fracture with nonunion P- subsequent encounter for fracture with malunion S- sequela Navicular Fracture ICD-9 825.22 Fracture of navicular (scaphoid), foot Navicular Fracture Etiology[eorif.com]
  • […] scan has a high sensitivity, it is also non-specific and requires additional diagnostic testing in the event of a positive test, further delaying the definitive diagnosis.11 Bone scans are unable to differentiate navicular pathology from other possible etiologies[podiatrytoday.com]

Epidemiology

  • […] encounter for fracture with delayed healing K- subsequent encounter for fracture with nonunion P- subsequent encounter for fracture with malunion S- sequela Navicular Fracture ICD-9 825.22 Fracture of navicular (scaphoid), foot Navicular Fracture Etiology / Epidemiology[eorif.com]
  • Stress Fractures: Pathophysiology, Epidemiology, and Risk Factors. Current Osteoporosis Reports, 4(3), 103-109. Wohl, G. R., Towler, D. A., & Silva, M. J. (2009).[raynersmale.com]
  • During this procedure, slight excavation of the edge of the trapezium bone may be necessary to reach the scaphoid as 80% of this bone is covered with articular cartilage, which makes it difficult to gain access to the scaphoid. [12] Epidemiology [ edit[en.wikipedia.org]
Sex distribution
Age distribution

Pathophysiology

  • Stress Fractures: Pathophysiology, Epidemiology, and Risk Factors. Current Osteoporosis Reports, 4(3), 103-109. Wohl, G. R., Towler, D. A., & Silva, M. J. (2009).[raynersmale.com]
  • Tarsal navicular stress fracture in a young athlete: Case report with clinical, radiologic, and pathophysiologic correlations. J Am Board Fam Pract. 2001 Sep-Oct;14(5):381-5. 17. Alfred RH, Belhobek G, Bergfeld JA.[podiatrytoday.com]

Prevention

  • Prevention The ultimate key to reduce the chances of navicular stress fractures is prevention.[newhealthadvisor.com]
  • Build strong muscles and practice balancing exercises to prevent falls.[winchesterhospital.org]
  • Even if the first X-rays do not show a fracture, your doctor still may treat you to prevent possible problems with healing. Right after the injury, you may wear a splint because your wrist is too swollen to put a cast on.[northshore.org]
  • Prevention of a Navicular Fracture Always wear shock absorbent and supportive footwear suited specifically for your activities. To avoid overuse, warm up correctly and be responsible with your exercise, learning to stop if your muscles are weakened.[medic8.com]
  • I run with orthotics to prevent this from happening in the future. In your case, you seem to have caught it early, and might not have too much time off. Hopefully this helps. Good luck.[letsrun.com]

References

Article

  1. Khan KM, Fuller PJ, Brukner PD, Kearney C, Burry HC. Outcome of conservative and surgical management of navicular stress fracture in athletes. Eighty-six cases proven with computerized tomography. Am J Sports Med. 1992;20:657-66.
  2. Torg JS, Pavlov H, Cooley LH, et al. Stress fractures of the tarsal navicular. A retrospective review of twenty-one cases. J Bone Joint Surg [Am]. 1982;64:700–12.
  3. Ting A, King W, Yocum L, et al. Stress fractures of the tarsal navicular in long-distance runners. Clin Sports Med. 1988;7:89-101.
  4. Quirk R. Stress fractures of the navicular. Foot Ankle Int. 1998;19:494–6.
  5. Evans J, Beingnessner D, Agel J, Benirschke SK. Minifragment plate fixation of high-energy navicular body fractures. Foot Ankle Int. 2011;32:485.
  6. Heckman JD. Fractures and dislocations of the foot. Rockwood CA, Green DP, eds. Rockwood and Green's Fractures in Adults. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1996. 2355-62.
  7. Potter NJ, Brukner PD, Makdissi M, Crossley K, Kiss ZS, Bradshaw C Navicular stress fractures: outcomes of surgical and conservative management. Br J Sports Med. 2006;40:692-5.
  8. Wedmore IS, Charette J. Emergency department evaluation and treatment of ankle and foot injuries. Emerg Med Clin North Am. 2000;18:85-113.
  9. 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.
  10. Rocket MS, Brage ME. Navicular body fractures: computerized tomography findings and mechanism of injury. J Foot Ankle Surg. 1997; 36:185–91.
  11. Harris G, Harris C. Imaging of tarsal navicular stress injury with a focus on MRI: A pictoral essay. J Med Imaging Radiat Oncol. 2016;60:359-64.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2017-08-09 15:27