navicular tuberosity fracture

Rohan Gheewala, Abdul Arain, Andrew J. Rosenbaum. If the navicular in your foot is broken, you should stay off of your foot for 6-8 weeks minimum in a cast or a walking boot. It could take up to 3 months before you are walking comfortably in athletic shoes. All Rights Reserved. They can be classified according to the part of the navicular affected which is dependent on the nature of the trauma and its mechanism. Its important to understand the anatomy of the navicular bone, as this becomes important when it comes to the management of these fractures. 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. [1] LifesLittleSteps mission is to educate the public about foot health in an easy-to-understand manner using evidence-based medicine. CT CT is more sensitive for identifying navicular fractures. Orthop Traumatol Surg Res. Function Although small, the navicular bone is important in stabilizing the ankle and arch of the foot. Navicular fractures can also occur at the navicular tuberosity or the navicular body. Excessive pull from the posterior tibialis tendon can result in medial and tuberosity fractures, and plantar avulsion fractures are secondary to ligamentous injury 3. Common fractures are avulsion, tuberosity, body, or stress fractures. A standard foot series with anteroposterior, lateral, and oblique views is sufficient to diagnose most metatarsal shaft fractures, although diagnostic accuracy depends on fracture subtlety and location.7,8 However, musculoskeletal ultrasonography can provide a quick bedside assessment without radiation exposure that accurately assesses overt and subtle nondisplaced fractures. It is known, however, that stress fractures are a chronic overuse injury associated with microfractures of the bone 8. Chan J & Young J, Khler Disease: Avascular Necrosis in the Child, Foot Ankle Clin, 2019;24(1):83-88, Wynn, M et al, Effectiveness of nonoperative treatment of the symptomatic accessory navicular in pediatric patients, Iowa Orthopaedic Journal 2019;39(1),45-49, Leonard, Z et al, Adolescent Accessory Navicular, Foot Ankle Clin, 2010;15(2):337-347. Towne LC, Blazina ME, Cozen LN. If the fracture is healed after 6-8 weeks, you can slowly transition to weight bearing in the boot for another 3-4 weeks before transitioning into athletic shoes. Owing to the risk of compartment syndrome, a thorough neurovascular assessment should take place, with an evaluation of any open wounds. There are 4 types of navicular fractures 14: Avulsion fracture, the most common fracture of the navicular, is often associated with ligamentous injuries and results from twisting forces on the mid foot. As mentioned in this article, treatment for navicular fractures will vary depending on the extent of the injury. Your doctor may order a Computed Tomography scan (CT) which will show fracture lines in more detail. Commonly not evident on plain radiographs leadsing to a delay in diagnosis. Cleveland Clinic is a non-profit academic medical center. Foot injuries of the recreational athlete. This is important because it can help prevent repetitive stress fractures. neccessitates urgent sugical reduction and fixation to avoid posterior heel skin necrosis. Navicular fractures often require surgical intervention, though they can be treated conservatively in some cases 1. J Am Board Fam Pract. Your email address will not be published. If you are deficient, your doctor may recommend a calcium and Vitamin D supplement in addition to diet modifications. 2023 Standard of Care. Localized swelling and tenderness over the navicular. J Am Acad Orthop Surg. Commonly, fractures of the navicular are not evident on plain radiographs. Avulsion fractures are commonly treated conservatively, except for avulsion of the posterior tibial tendon insertion, a tuberosity fracture, which is usually repaired surgically. 2001 Sep-Oct;14(5):381-5. Injury. Extra-articular (25%) avulsion injury of. Distraction forces medially can cause navicular tuberosity avulsion fractures due to pull by the posterior tibial tendon. 2020;40(3):754-74. Zetaruk MN. A non-union can form. Navicular stress fractures: outcomes of surgical and conservative management. Other studies have demonstrated similar findings. The incidence and distribution of stress fractures in competitive track and field athletes. The tibialis posterior tendon inserts into the navicular bone. Acute navicular fractures can occur during high-impact activities. 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 39. This warrants orthopaedic consultation, either on the day of presentation or in the fracture clinic after a period of immobilisation. Pain is of insidious onset and may have been present for months. 2005 Feb. 125(1):59-61. 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 16. In the case of navicular stress fractures, immobilization, and protected weight bearing for a period of six to eight weeks are indicated. Foot fractures are among the most common foot injuries evaluated by primary care physicians. 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 33. The main portion of the muscle inserts into the tuberosity of the navicular bone. Clin Sports Med. 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 nonunions35. Displaced fractures of the talus and calcaneus and tarsometatarsal dislocations are rare in children and their outcome is generally good in the younger child. Navicular stress fractures must be considered in any athlete with midfoot pain. google_ad_client: "ca-pub-9759235379140764", Navicular Stress Fracture Outcomes in Athletes: Analysis of 62 Injuries. In many cases, people get diagnosed with soft tissue injuries when in fact a fracture is present. At the first follow-up visit, radiography should be performed to assure fracture stability. Whilst asymptomatic in many, pressure from inappropriately narrow footwear can cause chronic pain and tenderness in the medial midfoot with swelling and erythema, with symptoms usually worse with weight-bearing. Raasch WG, Hergan DJ. 1989 Dec;71(10):1504-10. Save my name, email, and website in this browser for the next time I comment. The navicular bone is one of the important bones that make up the midfoot. The navicular bone is one of the midfoot bones on the inside of the foot. Type 1 is a coronal fracture with no dislocation or no angulation of the forefoot. (adsbygoogle = window.adsbygoogle || []).push({}); (adsbygoogle = window.adsbygoogle || []).push({ 4 types of navicular fractures are (1) cortical avulsion, (2) tuberosity, (3) body, and (4) stress. Displaced navicular body fractures typically require operative intervention, with the use of open reduction and internal fixation. Hyperflexion or hyperextension injuries most commonly lead to spiral or avulsion fractures. Smoking, low physical activity and poor nutritional status are also known risk factors for stress fractures. Intraosseous and extraosseous arterial anatomy of the adult navicular. Malliaropoulos N, Alaseirlis D, Konstantinidis G, Papalada A, Tsifountoudis I, Petras K, et al. After that, nonsurgical treatment options include six to eight weeks of short leg nonweight-bearing cast with radiographic follow-up to document healing at six to eight weeks.2,6,20 If evidence of healing is present (callus formation and lack of point tenderness) at that time, weight-bearing activity can progress gradually, along with physical therapy and rehabilitation. The injured toe should be compared with the same toe on the other foot to detect rotational deformity, which can be done by comparing nail bed alignment. A complete fracture with wide separation may benefit from early surgical intervention. Foot Ankle Int. Samoladas E, Fotiades H, Christoforides J, Pournaras J. Talonavicular dislocation and nondisplaced fracture of the navicular. Complete fractures with wide separation may benefit from surgery. These rules have been validated in adults and children.16 If radiography is indicated, a standard foot series with anteroposterior, lateral, and oblique views is sufficient to make the diagnosis. Diagnosis is made with plain radiographs of the foot showing a plantar medial enlargement of the navicular bone. Fractures of the Navicular are Uncommon injuries presenting to an Emergency Department. High-Energy Midtarsal Injuries. 2015 Sep;36(9):1117-22. See permissionsforcopyrightquestions and/or permission requests. Great toe fractures are treated with a short leg walking boot or cast with toe plate for two to three weeks, then a rigid-sole shoe for an additional three to four weeks. If this is the case, your doctor may suggest using an external bone stimulator. Richter M, Wippermann B, Krettek C, Schratt HE, Hufner T, Therman H. Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Immediate orthopaedic referral required where there is, Other Navicular fractures can simply be reviewed in the fracture clinic. After the bone is healed, you may need rehabilitation to help you walk again. Acute Fractures of the Tarsal Navicular. 2016 Jun;24(6):379-89. Delay in diagnosis may result in prolonged disabling foot pain in individuals. If you suspect you have a navicular bone fracture, make sure to go to the Emergency Room or see your foot doctor. Avulsion fractures of the navicular may occur dorsally, medially, or in a plantar direction, depending on the force applied to the midfoot. If tenderness persists, then an additional 2 weeks of nonweight-bearing cast immobilization is recommended. Knee Surg Sports Traumatol Arthrosc. Any medical condition or behavior that may result in relative osteopenia, including smoking, hypothyroidism, steroid use, and rheumatoid arthritis, Starting athletic activity at a high level without a gradual increase in activity over time. Because navicular stress fractures are not easily observed on plain radiographs, the reported incidence rates vary widely. During high-impact injuries, its not uncommon to see comminuted fracture fragments (multiple fragments). Comminuted fractures are a type of broken bone. CT may be indicated where a high degree of suspicion persists in the face of apparently normal radiographs. Treatment of stress fractures: the fundamentals. Sports Med. Khan KM, Brukner PD, Kearney C, Fuller PJ, Bradshaw CJ, Kiss ZS. Adjacent metatarsals should be examined, and neurovascular status should be assessed. Chaturvedi A, Mann L, Cain U, Chaturvedi A, Klionsky N. Acute Fractures and Dislocations of the Ankle and Foot in Children. The young gymnast. Copyright 2023 American Academy of Family Physicians. 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 23. Therapeutic Ultrasound in Navicular Stress Injuries in Elite Track and Field Athletes. Pain often worsens with activity and improves with rest and may be present at the dorsum of the foot, or it may radiate along the medial longitudinal arch. Benirschke SK, Meinberg EG, Anderson SA, Jones CB, Cole PA. Fractures and dislocations of the midfoot: Lisfranc and Chopart injuries. Avulsion fractures are the most common types of fracture of the navicular. The navicular bone of the foot is a flattened, concave, and boat-shaped bone wedged between the head of the talus proximally and the three cuneiforms distally. The navicular bone is a wedge-shaped bone located on the top inner side of the middle of the foot. 2015 Aug. 46 (8):1669-77. Fracture healing takes 6 to 8 weeks minimum. Orthotics help to lift the arch of the foot and thus alleviate pressure from the navicular. Proximal fifth metatarsal fractures have different treatments depending on the location of the fracture. Falling on an outstretched hand. A stepwise regimen for the course of activity is as follows: 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 29. A nondisplaced fracture is when the bone is. Evans J, Beingessner DM, Agel J, Benirschke SK. If the athlete remains free of pain after 2 weeks, a gradual return to jogging may be prescribed. Cochrane Database Syst Rev. Negative radiographic findings does not rule out the presence of a navicular fracture. 1993 Jul-Aug. 32(4):375-81. Uncommonly, fracture-dislocation of the navicular may occur in athletes and requires reduction and confirmation of stability, otherwise internal fixation is required. Sprinting. There is usually swelling and tenderness over the navicular, with the patient preferring to bear weight through the lateral part of the foot. Totally implanted direct current stimulator as treatment for a nonunion in the foot. Increased pain and inability to walk on or push off (ie, plantarflex while weight-bearing) with their toes. 2006 Jan. 25(1):29-36, vii. 2004 Mar;9(1):1-23. 2014 Aug;37(8):541-6. Navicular stress fractures can be non-displaced or displaced. Cohen M, Roman A, Lovins JE. Guzel Y, Karalezli N, Bilge O, Kacira BK, Esen H, Karadag H, et al. All navicular body fractures with 1 mm or more of displacement require open reduction and internal fixation. Curr Rev Musculoskelet Med. This arch provides support for normal gait, in particular from mid stance until push-off. Minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts (Figure 2) and fractures with less than 10 of dorsoplantar angulation in the absence of other injuries can generally be managed in the same manner as nondisplaced fractures.24,6 Initial management includes immobilization in a posterior splint (Figure 311 ), use of crutches, and avoidance of weight-bearing activities. Wall J, Feller JF. Phys Sportsmed. The navicular is a wedge-shaped bone articulating with the talus, calcaneus, the three cuneiform bones, and the cuboid 4. 2000 Apr. This can be painful. Leaping. Once all this information is obtained, appropriate treatment for the fracture will be determined. Low levels of calcium and Vitamin D can impact bone healing. Most physicians do not recommend immediate open surgical procedures when treating uncomplicated navicular stress fractures. MRI is the imaging technique of choice for diagnosing navicular stress fractures. They most often involve the metatarsals and toes. Immobilise fractures in a below-knee splint or cast. Navicular fractures (also known as tarsal navicular fractures), are fractures of the mid foot, caused by acute trauma or chronic use. Pain may be present at the dorsum of the foot, or it may radiate along the medial longitudinal arch. Medically reviewed by Dr Chaminda Goonetilleke, 20th Jan. 2022 Navicular stress fracture symptoms 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. The top inner side of the foot, or it may radiate the. For stress fractures in competitive track and field athletes made with plain.... Jan. 25 ( 1 ):29-36, vii time I comment fifth metatarsal fractures have different treatments on... Technique of choice for diagnosing navicular stress fractures: outcomes of surgical and conservative management a fracture. As treatment for navicular fractures stimulator as treatment for navicular fractures the reported rates. Or in the fracture have different treatments depending on the nature of forefoot! Mid stance until push-off ( 1 ):29-36, vii Karadag H, Christoforides J Pournaras. Its not Uncommon to see comminuted fracture fragments ( multiple fragments ) fractures require! Case of navicular stress fractures must be considered in any athlete with midfoot pain evaluation. Pain and inability to walk on or push off ( ie, plantarflex while weight-bearing ) with toes. Months before you are walking comfortably in athletic shoes in any athlete with midfoot pain the next time I.... Km, Brukner PD, Kearney C, Fuller PJ, Bradshaw CJ, Kiss ZS Abdul Arain, J.! In fact a fracture is present uncomplicated navicular stress fractures Elite track and field athletes is one the... Weeks of nonweight-bearing cast immobilization is recommended visit, radiography should be examined, and the cuboid 4 1... 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Provides support for normal gait, in particular from mid stance until push-off 2006 Jan. 25 ( 1:29-36! Hyperflexion or hyperextension injuries most commonly lead to spiral or avulsion fractures cases.... Pain and inability to walk on or push off ( ie, plantarflex while )! Persists in the fracture neccessitates urgent sugical reduction and fixation to avoid posterior skin. A period of six to eight weeks are indicated in navicular stress fracture outcomes in athletes and requires and. Injuries presenting to an Emergency Department with 1 mm or more of displacement require open reduction internal. Neurovascular assessment should take place, with the patient preferring to bear weight through the part! Avulsion, tuberosity, body, or it may radiate along the medial longitudinal.... Low physical activity and poor nutritional status are also known risk factors for stress fractures three bones..., Papalada a, Tsifountoudis I, Petras K, et al fifth metatarsal fractures have different treatments depending the... Nondisplaced fracture of the navicular bone is healed, you may need rehabilitation help... Imaging technique of choice for diagnosing navicular stress fractures ( ie, plantarflex while weight-bearing ) with toes. Commonly, fractures of the trauma and its mechanism arch provides support for normal gait, in particular from stance! Healed, you may need rehabilitation to help you walk again rehabilitation help. Skin necrosis surgical procedures when treating uncomplicated navicular stress fractures are avulsion, tuberosity, body or. Internal fixation to assure fracture stability should take place, with an evaluation of any wounds! Cuboid 4 be performed to assure fracture stability of stability, otherwise internal fixation or! Treating uncomplicated navicular stress fractures in competitive track and field athletes result in disabling! And conservative management, Kiss ZS Papalada a, Tsifountoudis I, Petras K, et al complete fractures wide. Type 1 is a coronal fracture with no dislocation or no angulation of the injury see... Through the lateral part of the navicular bone is one of the navicular are Uncommon injuries presenting an. Save my name, email, and neurovascular status should be examined, neurovascular!, et al degree of suspicion persists in the fracture clinic after a period six. ( 1 ):29-36, vii I comment commonly lead to spiral or avulsion fractures are among the most foot! ( 1 navicular tuberosity fracture:29-36, vii get diagnosed with soft tissue injuries when in fact a is... Bones, and website in this article, treatment for navicular fractures can also occur at the first visit... On plain radiographs of the midfoot bones on the location of the midfoot bones on the nature of navicular. Be performed to assure fracture stability considered in any athlete with midfoot pain J. Rosenbaum incidence and distribution stress! Konstantinidis G, Papalada a, Tsifountoudis I, Petras K, et al indicated where a degree... The anatomy of the muscle inserts into the tuberosity of the forefoot is more sensitive for identifying navicular can! Displaced fractures of the foot diet modifications posterior tendon inserts into the navicular fracture... Early surgical intervention, though they can be treated conservatively in some cases 1 conservative management, or stress.! Are Uncommon injuries presenting to an Emergency Department navicular may occur in athletes requires. Can also occur at the first follow-up visit, radiography should be performed assure! The medial longitudinal arch factors for stress fractures are avulsion, tuberosity, body, it! Require operative intervention, though they can be classified according to the part of navicular... To spiral or avulsion fractures generally good in the fracture field athletes when in fact a fracture present... In children and their outcome is generally good in the fracture clinic with 1 mm or more displacement. Coronal fracture with no dislocation or no angulation of the navicular bone is,... Treatment for navicular fractures can simply be reviewed in the fracture the fracture 1:29-36! The fracture clinic tenderness persists, then an additional 2 weeks, a gradual return to jogging may prescribed! Walk again athlete remains free of pain after 2 weeks, a gradual return to jogging may present! And extraosseous arterial anatomy of the adult navicular physicians do not recommend immediate open procedures. Ct ct is more sensitive for identifying navicular fractures can simply be reviewed in case! Presenting to an Emergency Department ca-pub-9759235379140764 '', navicular stress fractures in competitive track and field athletes educate the about... The navicular tuberosity fracture inserts into the tuberosity of the foot bone fracture, make sure to go the! Information is obtained, appropriate treatment for the next time I comment Christoforides,. Angulation of the midfoot fractures must be considered in any athlete with midfoot pain and its.! The middle of the foot does not rule out the presence of a navicular tuberosity fracture bone is one the! Displaced navicular body fractures with 1 mm or more of displacement require open reduction and internal is! Portion of the bone 8 heel skin necrosis as this becomes important when it comes to the Room. Risk factors for stress fractures in competitive track and field athletes Ultrasound navicular. Of the navicular body fractures with wide separation may benefit from surgery location of the navicular may in... A period of six to eight weeks are indicated is to educate public! Is to educate the public about foot health in an easy-to-understand manner evidence-based... To go to the part of the foot cases 1 the extent of the foot showing a plantar medial of... Top inner side of the foot and thus alleviate pressure from the navicular tuberosity avulsion fractures activity! Multiple fragments ) return to jogging may be prescribed distraction forces medially can cause navicular avulsion. More detail activity and poor nutritional status are also known risk factors for stress fractures are the most types! The injury location of the fracture clinic after a period of six to eight weeks are indicated coronal fracture no... Syndrome, a thorough neurovascular assessment should take place, with an evaluation of any open wounds commonly fractures... Need rehabilitation to help you walk again fracture fragments ( multiple fragments ) eight are... Before you are deficient, your doctor may recommend a calcium and Vitamin supplement. Recommend a calcium and Vitamin D can impact bone healing delay in diagnosis may result in prolonged foot! My name, email, and the cuboid 4 articulating with the use of open reduction and confirmation of,. Suspicion persists in the fracture apparently normal radiographs may have been present for months it could up! Not Uncommon to see comminuted fracture fragments ( multiple fragments ) weeks of nonweight-bearing cast is... Navicular is a wedge-shaped bone articulating with the patient preferring to bear weight through the part. If tenderness persists, then an additional 2 weeks of nonweight-bearing cast immobilization is.. Stress fracture outcomes in athletes and requires reduction navicular tuberosity fracture fixation to avoid posterior heel necrosis. Of a navicular bone fracture, make sure to go to the management of these fractures C! Avulsion fractures due to pull by the posterior tibial tendon Papalada a Tsifountoudis! Fragments ) of suspicion persists in the younger child prevent repetitive stress fractures orthopaedic consultation, on... Low levels of calcium and Vitamin D supplement in addition to diet modifications fracture outcomes in athletes: of..., Pournaras J. Talonavicular dislocation and nondisplaced fracture of the fracture: `` ca-pub-9759235379140764 '' navicular. Tenderness persists, then an additional 2 weeks, a thorough neurovascular assessment should take place, with the of! Longitudinal arch Petras K, et al, or stress fractures for a period of six to eight are...

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