Navicular fractures
Navicular fractures are typically caused by a twisting mechanism with forced plantar flexion or forced dorsiflexion of the midfoot. They present with severe pain over the dorsal or dorsomedial foot, particularly while bearing weight. Tenderness to palpation over the navicular bone generally warrants imaging studies to rule out fracture, as undiagnosed fractures can lead to severe long-term disability. Use Ottawa Ankle and Foot Rules12 in the acute setting to determine the need for radiographs. If imaging is indicated, obtain AP, lateral, and oblique views.
Tuberosity fractures may be seen on the AP view, while dorsal avulsions, talonavicular joint disruptions, and naviculo-cuneiform joint injuries are better seen on lateral views.16 Patients, particularly cross-country and track athletes, presenting with insidious onset of pain over the navicular bone should be evaluated for stress fracture using MRI, even in the presence of normal radiographs.
Differential diagnosis. Suspect Lisfranc joint complex injuries in any patient with mid-foot pain or fracture. The transverse arch of the foot is reliant upon the articulation of the second metatarsal with all 5 neighboring bones. The Lisfranc ligament is the strongest of 3 supporting ligaments to anchor the TMT joint complex. Other causes of mid-foot pain include soft tissue injury, contusion, and tendinopathy. In addition, other conditions that may cause pain in this area include cuboid syndrome, peroneal tendinopathy, Jones fracture, stress fracture, anterior calcaneal fracture, and sinus tarsi syndrome.
Treatment. Nondisplaced fractures of the cuboid or cuneiform may be treated with a short leg walking cast/boot for 6 weeks followed by the use of a shoe with a thin, rigid, longitudinal arch support for an additional 6 weeks.1 Fractures requiring referral for surgical evaluation include fractures that are open and fractures with vascular or neurological compromise. Also refer comminuted fractures and those that present with >2 mm step-off. Lastly, midfoot fractures that involve the Lisfranc joint should be immobilized and referred for orthopedic evaluation with instructions to the patient to avoid weight bearing until orthopedic evaluation.8
Avulsion fractures of the navicular bone may be managed nonoperatively with a short leg walking cast/boot if there is <20% involvement of the talonavicular surface. Simple nondisplaced body fractures may also be managed conservatively with immobilization and protected weight bearing for 6 to 8 weeks.15 Refer for surgical evaluation avulsion fractures that are intra-articular or dorsal involving 20% or more of the talonavicular surface and tuberosity fractures, given their risk of nonunion.9 All navicular body fractures that are not longitudinal in nature should also be referred for surgical evaluation. Navicular stress fractures that do not extend into the plantar cortex may be managed conservatively with a minimum of 6 weeks of a short leg cast and strict NWB with close follow-up.17
Continue to: Calcaneal fractures