Authors of section

Authors

Richard Buckley, Andrew Sands

Executive Editors

Joseph Schatzker

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Screw fixation

1. Diagnosis

History

Navicular fractures are often the result of high-energy injuries. In athletic injuries, they are most common in jumping sports, like basketball. The patient presents with either immediate or delayed pain.
In the multiply-injured patient, navicular fractures are often overlooked. These injuries are often picked up on the secondary survey. The unconscious patient should be carefully examined for unusual swelling or crepitus. If suspected, foot x-rays are indicated.

Physical exam

Often there is swelling and point tenderness. The split or stress fractures are as a rule not associated with any deformity. The higher-energy injuries (MVA or industrial/crush) are associated not only with marked soft-tissue trauma, but also with other injuries to the foot and deformity is more likely to be present.

Imaging

Plain x-rays often show a linear fracture line in the central portion of the navicular.
If a fracture is clinically suspected, but not evident on the x-ray, then proceed to other means of imaging. The TC99 bone scan may show an area of increased uptake and a CT and an MRI may give you a more definitive answer.

2. Principles

Talonavicular joint function

The talonavicular (TN) joint allows for hindfoot motion in all planes. Loss of TN motion results in loss of complex hindfoot circumduction. It is therefore extremely important to retain TN function as it has a protective function for the adjacent joints. Loss of TN motion leads to adjacent joint degeneration (DJD). Retaining even a small amount of motion is thought to be protective for the adjacent joint function. The TN joint, because of its extensive range of motion, is also known as the “coxa pedis”.

Click here to view animations of TN-joint motion in AP and lateral views.

nonoperative treatment

Simple fracture – maintain navicular concavity

When treating fractures of the navicular, it is important to maintain the concavity of the navicular.
In simple fractures, reduction compression devices may lead to overcompression and loss of shape and congruency. This affects talonavicular (TN) joint motion, if the tips of the reduction clamp are positioned to far proximally, a malreduction is usually the result. The tips should be positioned in such a way as to provide even compression across the fracture.

Maintain navicular concavity

Complex fracture

As described above, the shape of the TN joint is important. In comminuted fractures of the navicular, there is great danger of losing the normal geometry. Every attempt should be made to reconstruct the shape of the navicular while maintaining soft-tissue attachments and blood supply.

Blood supply
Blood supply

The navicular has an oval shape on cross-section. Small branches of the posterior tibial and dorsalis pedis arteries comprise the blood supply of the navicular. The medial and lateral areas are more or less well supplied while the central section has the most marginal blood supply.

Blood supply

Maintain medial column length

Medial column length is crucial in maintaining the shape of the medial arch of the foot.
If the navicular injury has resulted in comminution with loss of length, in reconstruction we must regain length, as well as normal geometry. Bridging the hardware distally and using bone graft will assure proper length of the medial column, overall shape and alignment of the foot.
The form and function of the foot is dependent on the normal relationship between the medial and lateral columns. If the relative lengths of the medial and lateral columns are not maintained, foot deformity such as cavus or planus results.
Relative shortening of the medial column leads to cavus whereas relative shortening of the lateral column leads to flat foot.

Weight-bearing triangle

3. Approaches

A dorsomedial approach is made directly over the fracture without peripheral dissection and undermining. This maintains the blood supply. The fracture is then entered directly and dealt with as necessary.

Approach

The percutaneous approach to the navicular may be used for screw fixation in nondisplaced or minimally displaced simple/noncomminuted fractures (ie, midbody stress fractures).

screw fixation

4. Reduction

Distraction

A medial-column distractor can be used to assist in inspection and reduction of the joint surface.
Distraction is particularly important if one is dealing with comminution or if a delay has occurred between the injury and the definitive reduction. Care must be taken to maintain medial column length and alignment.

Distraction

Compression

Insert the pointed reduction forceps through two small stab incisions placed dorsomedially and dorsolaterally. Remember to place the tips in the center of the fragments, since a proximal positioning of the tips may lead to malreduction.
Reduce the fracture carefully. Do not overcompress, since this will destroy the anatomical concavity of the joint surface.

Compression

Preliminary K-wire

Provisional fixation can be done using K-wires. If solid screws are to be used, be sure to place the K-wires so that they will not interfere with the subsequent screw placement.
If cannulated screws are used, the guide wires can be used for provisional fixation.
Take care not to penetrate the joint with the K-wires, or screws.

Preliminary K-wire

Check reduction

Ensure that the joint is anatomically reduced. Check reduction, if possible, under direct vision or by palpating the articular surface with an elevator. Use image intensification to check your reduction. Remember that the resolution of the image intensifier may not be sufficient to appreciate small joint incongruities. If in doubt, get intraoperative x-rays.

Checking reduction

5. Fixation

Screw insertion

Insert the first lag screw and carefully tighten it without overcompression.
Afterwards insert a second lag screw in the same fashion.
If the bone is porotic, insert a washer under the screw head to prevent it from sinking into the bone.

Screw insertion

6. Aftercare

Dressing
Non-adherent antibacterial dressing is applied as a first layer. Sterile undercast padding is placed from toes to knee. Extra side and posterior cushion padding is added.

Immobilization
A three-sided plaster splint is applied. The anterior area is left free of plaster to allow for swelling. Make sure that the medial and lateral vertical portions of the splint do not overlap anteriorly and that the splint does not compress the the popliteal space or the calf.

orif screw fixation

The plaster is then wrapped with more undercast padding.
The entire construct is then wrapped with elastic bandages.

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Follow-up
The patient should be counseled to keep the leg on a cushion and elevated. Remember not to elevate the leg too much as it may impede the inflow. The ideal position of the foot when the patient is supine is half way between the waist and the heart. While seated, the foot should be on a cushion and elevated, but if badly swollen the patient must be supine since elevating the foot while seated is not as effective in decreasing the swelling.

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The OR dressing is usually left in place and not changed until the first postoperative visit at 2 weeks, when x-rays are obtained once the dressing is removed. If any complication is suspected (e.g. infection or compartment syndrome) the dressing must be split and if necessary removed to allow full inspection.
Strict non-weight bearing should be maintained until there is evidence of healing, a minimum of 8 weeks.
If one should use a removable functional orthosis instead of cast, it may be removed daily to begin gentle range of motion.
Formal physical therapy should not begin in the early postoperative period.

orif screw fixation