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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].

Soft Tissue Swelling
  • However, if major soft tissue swelling or severe pain is present, a more serious ligamentous injury may have occurred and the patient should be kept non-weight bearing with immobilization for 6 weeks.[healio.com]
Thrombosis
  • Complications included one ipsilateral deep vein thrombosis, one avascular necrosis, one nonunion, seven infections (two deep and five superficial), and 56 cases of secondary osteoarthrosis (SOA). ORIF had significantly more SOA (χ(2) 0.000).[ncbi.nlm.nih.gov]
Insect Bite
  • .- ) frostbite ( T33-T34 ) insect bite or sting, venomous ( T63.4 ) Injuries to the ankle and foot S92 ICD-10-CM Diagnosis Code S92 Fracture of foot and toe, except ankle 2016 2017 2018 2019 Non-Billable/Non-Specific Code Note A fracture not indicated[icd10data.com]
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]
Osteopenia
  • Despite anatomic reduction of the navicular and initiation of early weight bearing, diffuse osteopenia is evident throughout the foot. Due to the patient’s other injuries, her mobility was significantly limited during the initial recovery period.[healio.com]

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].

Joint Space Narrowing
  • It leads to collapse of the navicular and joint space narrowing, which is most appropriately managed with fusion. Nonunion can also occur due to the bone’s limited blood supply.[healio.com]

Treatment

  • Treatment was 49/90 (55%) NOT and 41/90 (45.6%) ORIF. 11/41 (30%) ORIF required bone grafting.[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

  • Surgical repair by lag screw has been described to have a better prognosis. 2018 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA)[merckvetmanual.com]
  • 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]

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]
  • […] resorption requires 10 days to three weeks to allow visualization of these fractures on plain radiographs, even complete fractures are often not seen on initial films. 26 However, plain films are useful if positive, and they also assist in ruling out other etiologies[aafp.org]

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]
  • Epidemiology Frequency United States Navicular stress fractures may account for up to 35% of stress fractures in athletes. Because navicular stress fractures are not easily observed on plain radiographs, the reported incidence rates vary widely.[emedicine.medscape.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]
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;14:381-5. [ PUBMED ] 13. Torg JS, Pavlov H, Torg E. Overuse injuries in sport: The foot.[ijoonline.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 There is some evidence that Calcium and Vitamin D supplements decrease the incidence of stress fractures, particularly in females.[emedicine.medscape.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.

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Last updated: 2019-07-11 21:24