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Description
A man in his late teens presented to the orthopaedic trauma clinic with bilateral navicular fractures. He (a high-level athlete) had reported progressively worsening bilateral midfoot pain, likely as a result of repetitive navicular load. Although he was struggling, he continued to play for approximately six more months. At that point, he was in significant pain and rested both of his feet, mobilising in a wheelchair for four weeks. He tried to play again, however could not continue on.
CT scans of both feet showed bilateral fractures of the lateral aspects of the navicular bones with no evidence of collapse. On examination, he was found to have bilateral cavus feet with no swelling or tenderness along the navicular bones. He exhibited significant tightness of the gastrocnemius muscles with a positive Silfverskold test bilaterally. He underwent open reduction internal fixation of the right navicular through a sinus tarsi approach with a single 3-mm cannulated compression screw, and there were no significant perioperative complications (figure 1). He was initially non-weightbearing for six weeks and his postoperative course was uncomplicated. He underwent the same procedure for the contralateral side four months later (figure 2).
Computed tomography A) axial, B) coronal, and C) sagittal images demonstrating isolated fracture of the right navicular bone and D) intraoperative fluoroscopic imaging of fixation.
Computed tomography A) axial, B) coronal, and C) sagittal images demonstrating isolated fracture of the left navicular bone and D) intraoperative fluoroscopic imaging of fixation.
Tarsal navicular fractures make up approximately 5% of all foot fractures, and 35% of midfoot fractures.1 Acute navicular fractures are commonly a result of either high-energy trauma or repetitive stress. Due to strong surrounding anatomical and ligamentous support structures, this type of injury is generally associated with fractures of the adjacent bones of the foot and rarely happens in isolation. It follows on that simultaneous acute bilateral isolated navicular body fractures are extremely rare, with only one previous case reported in the literature to our knowledge.2
Acute navicular body fractures occur most commonly as a result of axial loading.3 They can occur as a progression of a stress fracture. Vertical stress is transmitted through the medial longitudinal arch of the foot, of which the navicular bone is a main component (figure 3). Restoring congruity of the arch with prompt anatomical reduction of the navicular bone is essential to avoid poor outcomes, such as midfoot arthrosis, as the navicular bone is vulnerable to osteonecrosis because of its complex blood supply.4 Navicular fractures are associated with significant morbidity and can be easily overlooked on both clinical exam and on plain film X-rays. The bilaterality seen in the case discussed impacts the decision-making process in terms of approach to treatment and timing of fixation for each side.
Force diagram outlining axial stresses on the A) calcaneus, B) navicular, and C) metatarsophalangeal joint. Original artwork by Orlagh Townsend.
Learning points
Acute navicular fractures are commonly a result of either high-energy trauma or repetitive stress—due to strong surrounding anatomical and ligamentous support structures, this type of injury rarely happens in isolation.
Restoring congruity of the arch with prompt anatomical reduction of the navicular bone is essential to avoid poor outcomes, such as midfoot arthrosis, as the navicular bone is vulnerable to osteonecrosis because of its complex blood supply.
Navicular fractures are associated with significant morbidity and can be easily overlooked on both clinical exam and on plain film X-rays.
Ethics statements
Patient consent for publication
Footnotes
Contributors OH and BM wrote the manuscript. MM and TB edited the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.