Internal Fixation of Tarsal Navicular Fractures
• 4.0-mm partially threaded cannulated screws (titanium preferred to allow for future MRI)
• Dental picks
• Small pointed reduction clamps
• Freer elevator
• 2.0-mm drill bit
• Kirschner wires (0.045, 0.054, and 0.062 in)
• Image intensifier/fluoroscopy (mini C-arm)
• Radiolucent table
• Padded bump underneath the ipsilateral buttock
• Esmarch supramalleolar tourniquet or pneumatic thigh tourniquet
• Advantageous for stress fractures in the mid to lateral third of the navicular bone.
• Dorsal longitudinal incision centered over the navicular bone, as localized with fluoroscopic imaging.
• The neurovascular structures (dorsalis pedis artery and superficial peroneal nerve branches) are identified and retracted medially.
• The extensor tendons (extensor hallics longus medially and extensor hallucis brevis laterally) are retracted.
• The periosteum of the navicular and the talonavicular joint capsule is incised to aid in identification of the fracture.
• It often is necessary to remove the dorsal cortical surface and any associated exostoses from the dorsum of the talonavicular joint to clearly identify the fracture site (Fig. 66-1).
• The fracture site is debrided, with care taken to preserve the articular joint surfaces (Fig. 66-2).
• A small drill bit or Kirschner wire can be used to perforate the exposed bone surfaces within the fracture itself and is recommended in chronic cases where sclerosis is present (Fig. 66-3).
Figure 66-1 | Dorsal approach to navicular fracture with mobilization of dorsal exostosis using an osteotome (A) followed by removal using a small rongeur (B).