Navicular Fractures

Figure 13.1

AP and lateral radiographs showing a fracture-dislocation of the right navicular

Figure 13.2

Axial CT cut illustrating large displaced dorsomedial fragment of the navicular

Treatment and Timing of Surgery

Following examination and radiographic analysis of the injury, the hip dislocation was reduced. It was noted that the navicular dislocation was unable to be maintained in a reduced position. The patient was taken urgently to the operating room for open reduction internal fixation due to tenting of the skin and concern for skin necrosis.

Surgical Tact

Position

The patient was placed on the operating table in the supine position, with a thigh tourniquet. Once draped to the level of the tourniquet, the knee was flexed over a radiolucent triangle and the foot slightly elevated with respect to the opposite lower extremity, allowing for unimpeded lateral fluoroscopic views.

Approach

The tourniquet was not inflated. A dorsomedial incision was made extending from the distal talus to the distal medial cuneiform. Deep exposure involved retraction of the dorsalis pedis artery and deep peroneal nerve.

Fracture Reduction and Fixation

Bone fragments were identified, cleaned, and reduced using plantar pressure and manual distraction. Two main fragments across the central aspect of the navicular were held using a bone reduction forceps. This was then secured using a smooth Kirschner wire and two partially threaded cannulated 4.0-mm cancellous screws were placed from medial to lateral, one dorsal and the other plantar. These navicular screws were placed through two small medial stab incisions. The navicular was then pinned from the medial and intermediate cuneiform, through the navicular, into the talus with two smooth 2.0-mm Kirschner wires to provide additional stability to the medial column (Fig. 13.3). The wound was closed, after tourniquet release and saline irrigation, in layers with 2-0 Vicryl and 3-0 nylon sutures.

Figure 13.3

Postoperative radiographs showing fixation of the navicular and medial column

Postoperative Plan

An AO splint was applied. Antibiotics were maintained for 24 h perioperatively. The patient was instructed to maintain foot-flat touchdown weight bearing for 10 weeks. Elevation to heart level was instructed. The sutures were removed at 2 weeks, and the patient was placed into a removable cam-walker boot. Ankle and toe range-of-motion exercises were initiated. Pins were removed at 4 weeks without re-subluxation.

Outcome

The patient had multifocal post-injury pain, although his midfoot pain was mild. His primary complaint regarding his foot was swelling. He had diminished sensation in his saphenous nerve distribution that slowly improved. He returned to work 6 months post-injury. He was discharged from care 1 year post-injury. Final X-rays are shown (Fig. 13.4).

Figure 13.4

Final X-rays, 1 year post-injury

Case Presentation #2

A 34-year-old male involved in a motorcycle collision presented complaining of right-foot pain. No other complaints were noted. He was stable hemodynamically, and ATLS-based assessment revealed no other sites of injury. Skin was intact, with mild swelling over the midfoot. No neurovascular compromise was seen.

Injury Films

Radiographs and a CT were obtained (Figs. 13.5 and 13.6). 3D reconstruction images were created from CT data showing a comminuted navicular (Fig. 13.7).