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GettingAthletesBackInTheGameAfterNavicularStressFractures|PodiatryToday

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GettingAthletesBackInTheGameAfterNavicularStress
Fractures
Monday,01/26/15|2368reads

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IssueNumber: Volume28Issue2February2015(/issue/4854)
Author(s):SeanGrambart,DPM,FACFAS
Topics: SportsMedicine(/search?keywords=SportsMedicine)
Anavicularstressfracturecanbeadevastatinginjuryfortherecreationalandhighlevelathlete.
Theissuesoftenderivefromdifficultyindiagnosingtheinjuryandthefactthatthereisno
consensusonthebesttreatmentregimenfortheinjury.Severalyearsago,clinicianswouldinitially
provideconservativetreatmentwithprolongedimmobilizationinacast.However,surgical
interventiondoeshavethepotentialofleadingtoanearlierreturntoactivityfortheathletic
population.
Whileresearchersoriginallydescribedthenavicularashavinganareaofvascularity,thevascularity
ofthenavicularbonehasbeenimplicatedinpoorhealingforstressfractures.In1958,Waughand
colleaguesreviewed21pediatricnavicularsfromcadavers,rangingbetween0to19yearsinage.1
Theydescribedavariablenumberofvesselspenetratingradiallyfromthecortextothecenterofthe
navicularwitharelativelylessdensevascularsupplyinthecenterincomparisontothesubcortical
bone.Therewerealargevarietyofpatternsbasedontheageofthecadaverssothesefindings
maynottranslatetoolderathletes.
Torgandcoworkersevaluatedtheintrasseousbloodsupplyofthenavicularinfiveadultcadavers.2
Theyshowedthatmultiplevesselsenteredtheboneprimarilyfromthemedialandlateral
nonarticularcortexandextendedtowardthemiddleaspectofthebone,leavingthecentralonethird
ofthebonerelativelyavascular.
Morerecently,McKeonandcolleagueslookedatboththeintraosseousandextraasseousblood
supplytothenavicularinadults.3Theyused60belowthekneelegsfrom30cadavers.
ResearchersinjectedIndiainkandWardsbluelatexintotheanteriortibial,peronealandposterior
tibialarteries.Afterfreezingandthenthawingthesecadavers,authorsassessedthenavicular
vascularsupplyin51specimensandreviewedtheintraosseousvascularityin54specimens.The
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GettingAthletesBackInTheGameAfterNavicularStressFractures|PodiatryToday

resultsshowedthemedialtarsalbranchesofthedorsalispedisconsistentlysuppliedthedorsal
navicular(96.4percent).Lateraltarsalbranchesalsosuppliedthedorsalnavicular.Themedial
plantarbonereceivedbloodsupplyfromsmallbranchesofthesuperficialbranchofthemedial
plantarartery.Alargepercentageofthespecimenshadadiffuseintraosseousvascularsupply
throughoutthebonewhileonly11percentofspecimenshadanavascularzoneinthecentralthird
ofthenavicularextendingtothedorsalcortex.Theauthorsconcludedthatbiomechanicalorother
clinicalfactorsmightplayamoreprominentroleinthesetypesofstressfractures.
Otherbiomechanicalfactorscanleadtostressfractures.Thereisazoneofmaximumshearalong
thecentralonethirdofthebodyofthenavicular.4Thetheoryisthatwiththefootinequinusduring
thefootstrikephaseofrunning,compressionforcesgeneratefromdistaltoproximalacrossthe
medialandlateralaspectsofthenavicularthroughthefirstandsecondmetatarsocuneiformjoints
respectively.Thetalarheaddirectlyresiststheforcesacrossthefirstmetatarsalandmedial
cuneiformbutdoesnotresistforcesacrossthesecondmetatarsalandmiddlecuneiform.The
navicularexperiencesazoneofmaximalshearstressbetweenthesetwocompressionforces.This
pointisthecentralonethirdofthenavicularandisjustlateraltothecenterofthetalarheadinthe
talonaviculararticulation.
EssentialDiagnosticInsights
Ahighclinicalsuspicionisthebesttoolinitiallyformakinganaccuratediagnosis.Standard
radiographsareroutineandoneshouldstillordertheminitially,buttheyarefairlyinaccuratefor
diagnosis.Ifanavicularstressfractureishighonthedifferentialdiagnosis,Irecommendmagnetic
resonanceimaging(MRI).AMRIwillshowincreasedsignalintensityandextensiveedemawithin
thebody,andmayevenshowthefractureline.Theydoaidinidentifyinganyareasofavascularity.
IftheMRIshowschangeswithinthenavicularconsistentwithstressfractures,thenIrecommenda
computedtomography(CT)scantoevaluatethepersonalityofthestressfracture.
TheCTscanswillaccuratelyshowtheanatomyofthestressfractureandonecanbetterassess
anydisplacement.Scanshaveshownthatthetypicalfractureislocatedinthecentralonethirdof
thebone,isprimarilyonthedorsalaspectandusuallydoesnotpenetrateintotheplantarcortex.
Thisisimportantforplanningscrewplacement.Thefracturelinetendstobeoblique,anglingfrom
dorsomedialtoplantarlateral.Longtermfollowuphasalsoshownthatmedullarycystsandcortical
notchingoftenpersistaftercompletehealingofthefracture.5Thereiscommonlyanareaofa
scleroticappearingrimofcorticalbonepresentontheproximalarticularsurfaceofthenavicular.
ACloserLookAtTreatmentOptions
Treatmentoptionsstillincludeconservativeorsurgicalmanagement.Theliteraturedemonstrates
theabilityofthesefracturestohealwithoutsurgerybutoftenatthecostofprolongedcast
immobilizationandnonweightbearing.Surgicaltreatmentisbecomingmorecommonlyacceptedas
theprimarytreatmentintheathleteinordertominimizetimeawayfromactivityandriskof
refracture.
Surgicaltreatmentcommonlyconsistsofscrewfixationwithorwithoutbonegraft.Ihaveatendency
toerronthesideofgrafting.IftheCTscanshowsnosignsofanysclerosisofthebone,onecan
placetwopercutaneousscrews.However,inmyexperience,thisisoftentheexceptionratherthan
therule.Mostpatientspresentwithsomedegreeofsclerosis,whichrequiressometypeofgraft.
CaseS(/files/pt0215sports2.png)tudy:TreatingANavicularStressFractureInAPoleVaulter
Thecasepresentedisa20yearoldcollegepolevaulter,whohadpainonlandingfortwomonths
withoutanyhistoryoftrauma.TheAPradiographinthetopofthephotoatleftisnegativefora

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navicularstressfracture.TheMRIshowsincreasedsignalintensityofthenavicular
butnofractureline(seebottomofphotoatleft).TheCTscanconfirmsanavicular
stressfracture(seebottomrightphoto).
Thesurgicaltechniqueisanoutpatientprocedureutilizingageneralanesthetic
andthightourniquet.Placeadorsalincisionandtakecaretoavoidthe
neurovascularstructuresincludingth
(/files/pt0215sports1_1.png)emedialdorsalcutaneousnerve
thatoccasionallycanbevisible.Deepenthedissectiontothe
talonavicularcapsuleandincisethecapsule.Iliketovisualizethe
articularsurfaceofthenaviculartocheckforanypossiblecartilagedamage.
Identifythefracturesiteandremovethefibroustissue,slightlyopeningthedorsal
cortex.Thedistalandproximalextentofthefractureshouldbefullyvisible.Thesurgeonneedsto
removeallofthescleroticbone.Onewouldusuallydrillthefracturesitewitha3.2mmdrillbitboth
mediallyandlaterallytostimulatebloodflowtothearea.Itisimportanttoreleasethetourniquetat
thistimetocheckforadequateremovalofthescleroticboneandthereturnofbloodflowmedially
andlaterally.Oneoftheerrorsthatleadstononunionsistheinadequateremovalofthesclerotic
bone.
Ipreferautologousbonegraftforthisfracture.Makeasmallincisionalongthelateralwallofthe
calcaneusinferiortothesuralnerve.Deependissectiondowntotheboneanduseainch
osteotometocreateasmallwindowalongthelateralwall.Savethislateralwallpieceforlateruse.
Useasmallrongeurtoremovethehealthycancellousbonefromthebodyofthecalcaneus.I
recommendbackfillingtheharvestsitewithallograftcancellousbonechipsforsupportand
scaffoldingtopromotehealing.Trytoreplacethelateralwallwithapieceoftheallograftbonechips.
(/files/pt0215sports3.png)Packtheautograftintothenavicularfracturesitewitha
bonetamp.Thenplacethelateralwallwindowtakenfromthecalcanealgraftas
thedorsalportionofthenavicularcortex.Performpercutaneousscrewfixation.
Typicalfixationconsistsof3.5or4.0mmdiameterscrews.ThepreoperativeCT
scanisimportanttodetermineplacementofthescrews.Onecanplacethescrews
eithermediallyorlaterally.Amedialtolateralorientationismostcommon.Thefirstscrewislocated
superiorandalongtheproximalnavicular.Thesecondscrewisparalleltothefirst,justslightly
inferioranddistal.
Postoperativerecoveryconsistsoftwoweeksnonweightbearinginaposteriorsplintfollowedby
twoweeksnonweightbearinginaremovablecastbootthatpatientscantakeofffordorsiflexionand
plantarflexion.TakenonweightbearingXraysatthispoint.Ifhealingisoccurringasexpected,the
patientcanbeginweightbearinginthebootastoleratedforfourweeks.Ateightweekspostop,
obtainXrays.
(/files/pt0215sports4.png)Ifthepatientisnotinthemiddleofaseason,heorshe
canstartlowimpactactivitiesundertheguidanceofatrainerorphysicaltherapist
forfourweeks,andthenadvancetoactivitiesastolerated.Ifpatientsareinthe
middleofaseason,IwilloftengetaCTscanateightweekspostoptoseeifthey
canstarttoadvanceactivitiesundertheguidanceofatrainerorphysicaltherapist.
IwillhavethepatientfollowupinfourweekswithXrays.
InConclusion
Navicularstressfracturescanbedebilitatinganddifficulttorecoverfrom.Surgicalinterventioncan
leadtopredictableresultswithanearlierreturntoactivities.
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Dr.GrambartisthefootandanklesurgeonfortheDivisionofOrthopedicsfortheCarleClinic
AssociationinChampaign,Ill.HeisaClinicalInstructorattheUniversityofIllinoisSchoolof
Medicine.Dr.GrambartisaFellowandmemberoftheBoardofDirectorsoftheAmericanCollege
ofFootandAnkleSurgeons.
References
1. WaughW.Theossificationandvascularisationofthetarsalnavicularandtheirrelationto
Kohlersdisease.JBoneJointSurgBr.195840B(4):76577.
2. TorgJS,PavlovH,CooleyLH,etal.Stressfracturesofthetarsalnavicular.Aretrospective
reviewoftwentyonecases.JBoneJointSurgAm.198264(5):70012.
3. McKeonKE,McCormickJJ,JohnsonJE,KleinSE.Intraosseousandextraosseousarterial
anatomyoftheadultnavicular.FootAnkleInt.201233(10):85761.
4. FitchKD,BlackwellJB,GilmourWN.Operationfornonunionofstressfractureofthetarsal
navicular.JBoneJointSurgBr.198971(1):10510.
5. KissZS,KhanKM,FullerPJ.Stressfracturesofthetarsalnavicularbone:CTfindingsin55
cases.AJRAmJRoentgenol.1993160(1):1115.
Editorsnote:Forrelatedarticles,seeKeyInsightsForTreatingNavicularStressFracturesinthe
October2008issueofPodiatryTodayorWhatYouShouldKnowAboutNavicularStressFractures
intheNovember2010issue.

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