Navicular fracture causes, symptoms, diagnosis, treatment & prognosis (2022)

Contents

  • Navicular fracture
    • Navicular fracture types
      • Navicular avulsion fracture
      • Navicular body fracture
      • Navicular stress fracture
    • Navicular fracture causes
    • Navicular fracture prevention
    • Navicular fracture symptoms
    • Navicular fracture complications
    • Navicular fracture diagnosis
    • Navicular fracture treatment
      • Rehabilitation program
      • Surgical treatment
      • Other treatment
    • Navicular fracture prognosis

Navicular fracture also called tarsal navicular fracture, most commonly the result of either traumatic injury or undue stress, with the latter having a higher incidence in younger individuals and athletes 1). Even though midfoot fractures are relatively uncommon injuries, navicular stress fractures represent up to one-third of all stress fractures 2). Navicular fractures are at high risk of nonunion and osteonecrosis owing to the navicular bone’s tenuous blood supply as well as the inherent complexity of the joint 3). Navicular fractures often require surgical intervention, though they can be treated conservatively in some cases 4).

The navicular is a wedge-shaped bone articulating with the talus, calcaneus, the three cuneiform bones, and the cuboid 5). The bone’s major oblique axis lies dorsoplantar and lateromedial, with its base situated dorsolaterally, and its apex plantar medial 6). The navicular is part of 2 important structures that are essential for normal gait: (1) the medial longitudinal arch and (2) the transverse tarsal joint (also called the midtarsal or Chopart joint).

Posteriorly, the navicular has a biconcave surface which articulates with the head of the talus 7). Anteriorly, the navicular has plantar concavity, with there being three articular surfaces 8). The largest of these surfaces is found medially with a convex surface, articulating with the medial cuneiform 9). The navicular tuberosity, found medially, is the insertion site for the posterior tibial tendon. Considering the large number of articulations found on the various surfaces of the navicular, a large portion of the bone is covered in articular cartilage.

The medial longitudinal arch is composed of the navicular, calcaneus, talus, 3 cuneiforms, and 3 medial metatarsals. This arch provides support for normal gait, in particular from mid stance until push-off.

The transverse tarsal joint is essential for normal gait and is composed of the talonavicular joint and the calcaneocuboid joint. At heel strike, this joint is flexible and plays an important role in absorbing ground impact and accommodating the foot to the ground. At push-off, the transverse tarsal joint is locked and is helpful in forward propulsion.

The dorsal aspect of the navicular receives vascular supply by the medial tarsal branches of the dorsalis pedis artery, along with branches of the lateral tarsal artery10). Supplying the medial plantar aspect of the navicular is a branch of the tibialis posterior artery11). Some literature suggests a zone of avascularity from the central third to the distal cortex of the navicular, which may contribute to the avascular necrosis sometimes associated with these fractures 12).

Navicular bone is an essential component of the Chopart joint, which itself consists of the talonavicular and calcaneocuboid joints 13). Both of these joints are crucial for inversion and eversion of the foot.

Midfoot fractures only represent a small portion of all foot injuries, though stress fractures comprise approximately one-third of all stress fractures of the foot 14). 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. The overall incidence may appear to be increasing due to advances in imaging 15).

Among track-and-field athletes, up to 21% may experience a stress fracture in the course of a year 16). In these athletes, up to 15% of stress fractures are of the navicular 17). Other studies have demonstrated similar findings. [28, 29, 30, 31] The highest incidence of stress fractures is in jumping and sprinting events.

(Video) Navicular Stress Fracture: Symptoms & Treatment

Among military recruits, the incidence is approaching that of athletes, as the training of military recruits closely mirrors the training of athletes 18).

In the case of traumatic navicular injuries, the vast majority result from motor vehicle accidents, followed by falls and blunt injuries 19). Stress fractures are most common in young individuals with high functional demand such as competitive athletes 20).

Navicular fracture types

There are 4 types of navicular fractures 21):

  1. Navicular avulsion fracture,
  2. Navicular tuberosity fracture,
  3. Navicular body fracture
  4. Navicular stress fracture.

Navicular avulsion fracture

Avulsion fracture, the most common fracture of the navicular, is often associated with ligamentous injuries and results from twisting forces on the mid foot. These fractures are commonly treated conservatively, except for avulsion of the posterior tibial tendon insertion (tuberosity fracture), which may be repaired operatively, especially if a proximal dislocation of 1 cm or more is present. An avulsion of the posterior tibial tendon insertion must be differentiated from an accessory navicular.

Navicular body fracture

Fractures of the navicular body are commonly associated with other injuries of the midtarsal joint. Sangeorzan et al 22) in 1989 categorized navicular body fractures into 3 types.The Sangeorzen classification system classifies tarsal navicular body fractures according to the direction of the fracture line, degree of disruption of surrounding joints, and the direction of foot displacement 23).

  • Type 1 is a coronal fracture with no dislocation or no angulation of the forefoot.
  • Type 2 is a dorsolateral to plantar-medial fracture fracture with medial displacement of the major fragment and forefoot.
  • Type 3 is a comminuted fracturein the sagittal plane of the bone with lateral forefoot displacement and carries the worst prognosis.

All navicular body fractures with 1 mm or more of displacement require open reduction and internal fixation.

Navicular stress fracture

Navicular stress fractures are usually sports-related injuries.

In 1855, Brehaulpt first described stress fractures in military recruits who were subjected to long marches. As more civilians took up physically demanding sports, the incidence of stress fractures has increased in the general population. Towne et al first described stress fracture of the tarsal navicular in 1970 24).

In athletes, navicular stress fractures are of particular concern because they are underdiagnosed and can lead to significant disability if the diagnosis is delayed 25). In a study by Torg et al 26) in 1982, the average time between the fracture and diagnosis was estimated to be 7 months. Given the significant improvement in outcome with early diagnosis and proper treatment, navicular stress fractures should be considered in any athlete with midfoot pain. In a 2006 study by Saxena and Fullem 27), navicular stress fractures took up to 4 months to heal posttreatment.

Fracture-dislocation of the navicular may occur in athletes 28). This uncommon injury generally requires reduction and examination for stability via fluoroscopy, with the patient under general anesthesia. If the postreduction examination findings confirm stability of the navicular, treatment with a non–weight-bearing cast may be sufficient; otherwise, internal fixation is required.

Navicular fracture causes

While the biomechanics behind stress fractures of the tarsal navicular are somewhat poorly understood, those of traumatic injuries are more comprehensively elucidated. It is known, however, that stress fractures are a chronic overuse injury associated with microfractures of the bone 29). Traumatic injuries can cause a variety of navicular fracture patterns, including avulsion fractures, tuberosity fractures, and body fractures.

(Video) Accessory Navicular Bone - Everything You Need To Know - Dr. Nabil Ebraheim

Avulsion fractures of the navicular may occur dorsally, medially, or in a plantar direction, depending on the force applied to the midfoot. In the case of foot dorsal avulsion, fractures result from extreme plantar flexion causing undue stress on the deltoid and dorsal capsules30). Excessive pull from the posterior tibialis tendon can result in medial and tuberosity fractures, and plantar avulsion fractures are secondary to ligamentous injury 31).

Navicular body fractures can be caused either by a direct or an indirect force. There are several other theories on the forces causing navicular body fractures, though all are due to axial forces on a foot in plantar flexion 32).

Some risk factors for navicular stress fracture include the following:

  • Female sex
  • Menstrual irregularities 33)
  • Unequal leg length
  • Any medical condition or behavior that may result in relative osteopenia, including smoking, hypothyroidism, steroid use, and rheumatoid arthritis
  • Sudden, significant weight loss

Some factors that have been implicated as causes of navicular stress fractures include the following:

  • Starting athletic activity at a high level without a gradual increase in activity over time
  • Starting a second sport and assuming that the body is conditioned to participate at that sport immediately and at a high level. The navicular is at particular risk when runners participate in sports that require jumping and do not take the time for proper conditioning in their new sport.
  • Ill-fitting and/or old, worn equipment
  • Change in running or field surfaces
  • Relative osteopenia
  • Biomechanical abnormality.

Navicular fracture prevention

There is some evidence that Calcium and Vitamin D supplements decrease the incidence of stress fractures, particularly in females. Smoking, low physical activity and poor nutritional status are also known risk factors for stress fractures.

Navicular fracture symptoms

Patients of navicular avulsion fractures typically present with a significant degree of pain in the midfoot area, particularly during push-off of the fractured segment. Patients who have endured a navicular body fracture are typically unable to bear any weight on the affected extremity and present with a profound degree of swelling on the dorsal and medial aspects of the foot, all of which is due to the mechanism of the injury and disruption of the medial column of the foot34). Owing to the risk of compartment syndrome, a thorough neurovascular assessment should take place, with an evaluation of any open wounds. Additionally, navicular body injuries are often associated with additional injuries on the ipsilateral foot, with a recent study showing fifteen patients out of twenty-four having further injuries 35).

On the other hand, patients who have endured a navicular stress fracture typically have a milder clinical presentation, with an extended history of vague midfoot discomfort. Examination of these patients typically reveals a well-localized source of their pain over the dorsal aspect of the midsection of the navicular 36).

Navicular stress fractures must be considered in any athlete with midfoot pain. Typically, the pain is of insidious onset and may have been present for months. In addition, the pain often worsens with activity and improves with rest. Pain may be present at the dorsum of the foot, or it may radiate along the medial longitudinal arch. Slight swelling may or may not be present.

Historically, persons participating in the following sports and activities have a relatively high risk of navicular fracture:

  • Track and field – Particularly sports involving jumping and sprinting 37)
  • Ballet and other dancing activities 38)
  • Equestrian sports
  • Basketball
  • Soccer 39)
  • American football
  • Australian-rules football
  • Rugby
  • Gymnastics 40)
  • Military training 41)

Physical examination

Possible findings from the physical examination in an individual who has a navicular fracture include the following:

(Video) Calcaneal Stress Fractures identification and treatment

  • Tenderness at the “N spot,” which is defined as the proximal dorsal portion of the navicular (see the image below). This is the most important physical finding.
  • Tenderness at the midmedial arch over the navicular
  • Pain with passive eversion
  • Pain with active inversion
  • Pain that is often reproduced if the patient hops while in the equinus position
  • Possible mild dorsal midfoot swelling

Figure 1. Navicular fracture N spot

Navicular fracture complications

As with most periarticular regions, there are several potential complications and risks associated with fractures of the navicular. These complications include osteonecrosis, malunion, nonunion, persistent stiffness, and pain. Patients suffering a nonunion may have deformity which can be mitigated through the use of an orthosis or surgical revision, depending on the severity of the deformity. Osteonecrosis, however, can result in profound deformity and is typically treated with the primary goal of restoring length and alignment, which is often through the fusion of the talonavicular or naviculocuneiform joints 42).

Navicular fracture diagnosis

In a patient with a suspected tarsal navicular fracture, the initial radiographic evaluation is the three-view radiograph of the foot; this includes a non-weight bearing anteroposterior, lateral, and oblique X-ray. However, patients with suspected ligamentous injury or minor injuries may require a weight-bearing radiograph. An external oblique radiograph of the foot is useful in the evaluation of a suspected tuberosity fracture43). In evaluating radiographs, the clinician should be aware of the potential for the appearance of an accessory navicular, which is identifiable with a radiograph of the contralateral foot.

The use of computed tomography (CT) can be helpful in high-energy injuries, as it can more precisely delineate complex fracture patterns, the geometry of the talonavicular joint, and can assist in preoperative planning. Additionally, CT can be used to create three-dimensional reconstructions of the navicular.

Navicular fracture treatment

Tarsal navicular fractures can be managed either nonsurgically or surgically, depending on the individual fracture characteristics, such as the size, the degree of displacement, the location, comminution, as well as the condition and integrity of the soft tissues of foot, the presence of additional injuries on the ipsilateral foot, comorbidities and overall functional status 44).

In the case of navicular stress fractures, immobilization, and protected weight bearing for a period of six to eight weeks are indicated. However, patients with high functional demand, such as athletes may opt for surgical intervention instead45). In the event of surgical intervention, these fractures may undergo repair with open reduction and internal fixation 46).

The management of traumatic navicular fractures can also be surgical or nonsurgical. Small avulsion fractures, tuberosity fractures, and nondisplaced body fractures can be managed nonoperatively, with the use of a weight-bearing short leg cast and ultimately a walking boot 47).

Displaced navicular body fractures typically require operative intervention, with the use of open reduction and internal fixation. The goals of operative intervention are anatomic fracture reduction, restoration of the length of the medial column, and creation of a rigid osseous construct which would allow for early range of motion 48).

Rehabilitation program

After the affected foot has been placed in a non–weight-bearing cast for 6 weeks, the cast is removed and tenderness at the N spot is assessed. If tenderness persists, then an additional 2 weeks of non–weight-bearing cast immobilization is recommended. However, if tenderness is not present at the N spot, then weight-bearing activity may begin. This activity is limited to a gradual return to normal activity under the care of a sports physician or physical therapist. The therapy may include muscle strengthening, range-of-motion exercises, and soft-tissue massage.

(Video) Clinical Management of Leg and Foot Stress Fractures

A stepwise regimen for the course of activity is as follows:

  1. The patient participates in his or her normal activities of daily life (ADLs), which may include swimming, for 2 weeks (Weeks 1 and 2).
  2. If the athlete remains free of pain after 2 weeks, a gradual return to jogging may be prescribed.
  3. After 2 weeks of a gradually progressive jogging regimen (Weeks 3 and 4), the patient is again assessed for pain.
  4. If the patient remains free from pain after 2 weeks after gradually progressing in the jogging regimen, then the athlete may gradually return to full activity over the final 2 weeks of the rehabilitation program (Weeks 5 and 6).

Therapeutic Ultrasound may have a role in determining return to play decisions as pain with therapeutic ultrasound has corelated with MRI finding in navicular stress injuries 49).

Medical issues and complications

Delayed union and nonunion produce persistent pain at the navicular 50). Plain radiographs and/or a CT scan may show the persistent fracture. In such cases, referral to a surgeon is required for open reduction and fixation. In addition, fracture of the tarsal navicular may be complicated by avascular necrosis.

Surgical treatment

Most physicians do not recommend immediate open surgical procedures when treating uncomplicated navicular stress fractures. In a comparison study by Potter et al 51), surgery had similar long-term return-to-activity rates relative to conservative therapy. In another study, bone healing took up to 4 months, for both operative and nonoperative treatment 52).

Fractures that are complicated by dislocation are assessed for stability following reduction. If the navicular is stable, then treatment may continue as outlined for uncomplicated navicular fractures. If the navicular is unstable, then internal fixation is required.

A complete fracture with wide separation may benefit from early surgical intervention. In addition, if the patient is not expected to tolerate the rehabilitation program, surgical correction may be considered.

Return to sport, particularly in elite athletes, may be quicker with surgical vs non-surgical treatment 53).

A retrospective analysis by Coulibaly et al that compared operative and non-operative treatment of navicular fractures reported that the operative treatment group had considerably more complications of secondary osteoarthritis 54).

Other treatment

Although no trials support the use of bone growth stimulators for navicular stress fractures, they may be a helpful adjunct55). In particular, bone growth stimulators that use pulsed electromagnetic fields (PEMFs) have been shown to have similar success rates when compared with open repair in tibial fracture nonunions56). Whether these results are applicable to acute fractures and fractures of the navicular remains to be determined.

Platelet-rich plasma may help bone healing. Whole blood taken from the patient is processed to be used at the injury site. Although evidence suggests that platelet-rich plasma is safe and can promote bone formation, no clear evidence of benefit in fracture healing has been reported 57). No controlled trials of platelet-rich plasma use in healing of navicular fractures are underway 58).

(Video) NAVICULAR DISEASE IN HORSES

Navicular fracture prognosis

Patients who have suffered a navicular stress fracture typically have a favorable prognosis if treated promptly and appropriately. A recent study demonstrated that 57 out of their 62-patient cohort had been able to return to activity at their preinjury level, implying an optimal clinical outcome59). In another case study of 10 patients who had suffered comminuted tarsal navicular fractures, the union was achievable in all surgically treated patients, with none requiring an arthrodesis at a mean follow up of 20 months 60).

References[ + ]

FAQs

What are the symptoms of a navicular fracture? ›

Symptoms. Patients with navicular stress fractures usually have gradual onset of aching pain across the top and/or middle of the foot. Pain usually improves with rest and support but then returns when activity resumes.

How is a navicular fracture treated? ›

Most treatment options for navicular fractures in your foot or wrist are non-surgical and focus on resting the injured area for six to eight weeks in a non-weight-bearing cast. Surgical treatment is generally chosen by athletes wanting to return to normal activity levels at a faster rate.

What causes navicular fracture? ›

Navicular stress fractures are often caused by repetitive stress placed on the foot. The injury usually happens to athletes who play sports that involve running, jumping, or twisting. These activities pinch the navicular between the ankle bone and the cuneiform bones. Over time, this force can cause a stress fracture.

How long does it take for a navicular fracture to heal? ›

It will take about 6 weeks for most people to heal. The goals of treatment are to manage pain and support the bone as it heals. This may include: Medicine to ease pain and swelling.

How serious is a navicular fracture? ›

All tarsal navicular stress fractures are considered high-risk because non-healing stress fractures are common with either conservative or surgical treatments, due to the poor blood supply to the bone. Return to play can take several weeks and even months with either type of treatment.

Can you walk with a fractured navicular? ›

In most cases a navicular fracture can be treated conservatively by implementing a cast that immobilises the injured foot for around 6 weeks while the fracture heals. During this period it will be necessary to use crutches to walk and to avoid much weight bearing.

Do navicular fractures require surgery? ›

Navicular stress fractures are relatively common, most effectively treated by either non‐weightbearing cast immobilisation or surgical fixation, followed by a graded return to sport. These treatments appear equally effective over the short term.

Do navicular fractures heal? ›

They reported 100% successful outcomes in incomplete or non-displaced complete navicular stress fractures treated with 6 weeks in a NWB cast. This has generally been considered to be the gold standard treatment for these injuries.

Can navicular bone heal? ›

Because of the location and function of the navicular bone, and also because circulation in this area is not robust, healing can take several months before normal function is restored. Sports massage may also help speed healing by stimulating circulation to the foot, ankle, and calf.

What causes pain in navicular bone? ›

Fracture and arthritis are common causes of pain. Less common but other important causes of Navicular pain include ligament injury, irritation of low back nerves, and Accessory Navicular syndrome.

How common is a navicular fracture? ›

A navicular fracture is rare but can be seen, especially in athletes.

How is a navicular stress fracture diagnosed? ›

A CT scan can show the exact location and size of a navicular fracture. It's sensitive to partial fractures, which are often seen coursing from the proximal dorsal central-third of the bone towards its distal plantar pole (3). The findings of the CT scan dictate the classification of a navicular stress fracture.

What is the fastest way to heal a stress fracture? ›

First Aid
  1. Rest. Avoid activities that put weight on your foot. ...
  2. Ice. Apply ice immediately after the injury to keep the swelling down. ...
  3. Compression. To prevent additional swelling, lightly wrap the area in a soft bandage.
  4. Elevation. As often as possible, rest with your foot raised up higher than your heart.

Can navicular stress fractures heal on their own? ›

Stress fractures generally heal on their own with simple measures, such as avoiding activities that put stress on the area. In some cases, however, surgery is needed to help the fracture heal properly.

Can a foot fracture heal without a cast? ›

To heal, a broken bone must be immobilized so that its ends can knit back together. In most cases, this requires a cast. Minor foot fractures may only need a removable brace, boot or shoe with a stiff sole.

How do you diagnose a stress fracture in your foot? ›

An imaging test, such as an X-ray, MRI, or bone scan, is required to accurately diagnose the location and extent of a stress fracture. Without proper diagnosis and treatment, a stress fracture can worsen and become a full fracture, causing more intense pain and possible displacement of the affected bone.

Where does a navicular stress fracture hurt? ›

Commonly occurring in track and field athletes (Table 1),1,5,7,10,13,17,18,2123 navicular stress fractures present as vague, aching pain in the dorsal midfoot that may radiate along the medial arch. The pain typically increases with activity such as running and jumping.

How do I know if I have a stress fracture in foot? ›

Pain, swelling or aching at the site of fracture. Tenderness or “pinpoint pain” when touched on the bone. Pain that begins after starting an activity and then resolves with rest. Pain that's present throughout the activity and does not go away after the activity has ended.

Can a navicular stress fracture heal on its own? ›

Stress fractures generally heal on their own with simple measures, such as avoiding activities that put stress on the area. In some cases, however, surgery is needed to help the fracture heal properly.

Do navicular fractures heal? ›

They reported 100% successful outcomes in incomplete or non-displaced complete navicular stress fractures treated with 6 weeks in a NWB cast. This has generally been considered to be the gold standard treatment for these injuries.

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