vol. 5 / no.

Foot & Ankle Specialist

Case Report
Isolated Tarsal Navicular
Fracture Dislocation

Ambarish A. Mathesul, MS,

Dhiraj V. Sonawane, MS, and
Varun K. Chouhan, MS

A Case Report

Abstract: Injuries to the midtarsal

joints are rare. They occur in the form
of various combinations such as fracture, fracture subluxation, and fracture dislocation. The largest series of 71
cases has been reported by Main and
Jowett in 1975. Isolated tarsal navicular dislocations are rare injuries.
Being rare, these injuries remain poorly
understood. Only few case reports exist,
which describe the probable mechanism of injury and optimal treatment. Of the few case reports, only one
describes closed reduction with external fixator and percutaneous fixation
as the treatment modality. This case
report emphasizes the use of external
fixation with pins in the calcaneum
and not in talus as described by the
earlier report.
Levels of Evidence: Therapeutic,
Level IV
Keywords: tarsal navicular fracture dislocation; closed reduction and external
fixation; percutaneous K-wire fixation

Introduction
Injuries of the midtarsal joints are
rare.1 Main and Jowett2 had described

the mechanism of injuries involving

Case Report
these joints. Displaced fractures of tarsal
A 50-year-old man, met with a road
navicular bone are uncommon because
traffic
accident. He presented to us in
the middle part of the foot is rigidly stathe
emergency
department with pain and
bilized by an extensive network of plan3
swelling
of
the
right foot. On detailed
tar and dorsal ligaments. Sangeorzan
3
history,
the
mechanism
of injury was
et al described the classification for
plantar
flexion
of
the
foot
with axial
fractures of the tarsal navicular bone.
loading.
Plain
radiograph
of
the right foot
Isolated fracture dislocation of tarsal
showed
isolated
fracture
dislocation
of
navicular is an extremely rare injury.
the
navicular
with
communited
plantar
Tarsal navicular acts as a keystone and
fragment (Sangeorzan type 1; Figure 1).
helps in maintaining
the medial longitudinal
arch of the foot, which
Navicular fractures should be reduced
is important for weight
bearing and locomoproperly and fixation should aim toward
tion. Navicular fractures
should be reduced propmaintaining the arches of the foot.
erly and fixation should
aim toward maintaining
Computed tomography scan (Figure 2)
the arches of the foot.4 Literature sugconfirmed
the radiographic findings with
gests that fracture dislocations of tarno
associated
tarsal bone fractures. The
sal navicular are to be managed by open
foot
was
immobilized
with a below knee
reduction and internal fixation, however,
2,3,5-7
slab
and
limb
elevation
was given. The
with compromised outcomes.
Earlier
limb
was
observed
till
the
swelling was
case report described minimal intervenreduced.
The
patient
was
operated
after
tion using external fixation with pins in
5
3
days
under
spinal
anesthesia.
Closed
talus in type 1 navicular fracture. We
reduction of navicular was achieved by
suggest the use of external fixation with
principle of ligamentotaxis using JESS
pins in the calcaneum, which is a safe
and technically easy procedure, and also (Joshis External Stabilization System) fixator with pins in metatarsals and calcagives adequate stability and maintains
neum on the medial side of foot. A 1.5
reduction.

DOI: 10.1177/1938640012439602. From the Department of Orthopaedics, King Edward VII Memorial Hospital, Mumbai, India (AAM, DVS) (VKC). Address correspondence
to Ambarish A. Mathesul, MS, Department of Orthopaedics, King Edward VII Memorial Hospital, 6th floor, Acharya Donde Marg, Parel, Mumbai 400012, India; e-mail: math
.amb123@gmail.com.
For reprints and permissions queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright 2012 The Author(s)

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Foot & Ankle Specialist

Figure 1.

Figure 3.

Figure 5.

Lateral preoperative radiograph showing

isolated communited fracture navicular
dislocation with normal talus.

Immediate postoperative radiograph

showing the reduced navicular with
external fixator (Joshis External
Stabilization System) and Kirschner wire.

(A) Anteroposterior and (B) lateral

radiograph of the foot with reduced
navicular.

Figure 2.

Figure 4.

Computed tomography scan confirming

the diagnosis. The major part of navicular
is dislocated dorsally.

A radiograph at 6-months follow-up

showing the well-reduced navicular.
Patient walking full weight bearing.

cm dorsal incision was taken; reduction

was achieved using 10 mm osteotome
and maintained using 2 mm Kirschner
wire (Figure 3). Postoperatively patient
was discharged on day 7 with a below
knee slab. Suture removal was done on
day 14, and below knee slab was discontinued. Patient was kept nonweight
bearing till 6 weeks. At 6 weeks, external fixator and Kirschner wire were
removed and partial weight bearing was
started. Full weight bearing was started
at 12 weeks. The American Orthopaedic
Foot and Ankle Society Score at 12 weeks
was 66. At 6 months, patient had no tenderness, and medial longitudinal arch
was maintained with full ankle range of
motion (Figure 4). At 12 months
follow-up, patient had a pain free, full

weight bearing walk and was able to

do his activities (Figures 5A and B). The
American Orthopaedic Foot and Ankle
Society Score was 97 at 12 months.

Discussion
Tarsal navicular fractures are rare injuries. Isolated tarsal navicular fracture dislocation is extremely rare. The described
methods for management of the fractures
and fracture dislocations of tarsal navicular are closed reduction, open reduction
and internal fixation, fusion procedures,
triple arthrodesis, and partial or total

excision.8 Open procedures involve

increased chances of wound complications, and the magnitude of each of these
procedures will necessarily be reflected
in resulting limitation of function.
Main and Jowett2 had classified midtarsal injuries into 5 different groups; the
fracture pattern described in our case
report falls in the longitudinal forces
group. They suggested open reduction
for these fracture/dislocation with fair
results. In the purely longitudinal group,
as the arch is disrupted with extrusion of
keystone, unreduced severe displacement
produced poor result.
Sangeorzan et al3 reported a series of 21
cases, 4 cases were of type 1. All 4 were

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Foot & Ankle Specialist

treated with open anteromedial incision and reduction with good initial outcome; however, on long-term functional
outcome of all the 21 cases, only 4 were
asymptomatic.
DeLee9 reported that in patients with
severely comminuted fractures, open
reduction and internal fixation with
Kirschner wires through the fracture fragments into the adjacent tarsal bones are
done in an effort to maintain the longitudinal and medial arches of the foot.
Kimura et al10 suggested fixation for
comminuted tarsal navicular with a screw
and transverse wire pinning through
the cuneiforms and cuboid as a satisfactory technique for the treatment of comminuted or osteoporotic fractures of the
tarsal navicular, especially in type 3,
because it maintain the arches and offers
early foot and ankle movement.
As described in this case, closed reduction was achieved by ligamentotaxis
using external fixator and further stability
was added by percutaneous Kirschnerwire pinning of the major fragments.
Closed reduction using ligamentotaxis
involves less extensive exposure, has
minimal chances of wound complications, and favorable outcome as arches
of foot are maintained as was seen in our
case. Literature review suggests localized
arthritis following minimal invasive procedures has better functional results than
extensive fusion procedures.3
This new technique of ligamentotaxis with fixator involves insertion of
pins in the metatarsals and talus5 or calcaneum. Talus has a small medial safe
zone (neck of talus) for pin insertion,
hence many pins cannot be inserted,

which may compromise construct stability. Also iatrogenic vascular injury to

the vessels of the tarsal canal may possibly lead to risk of osteonecrosis of the
talar body.
Calcaneum has a larger, readily definable rectangular medial safe zone,11
therefore, more number of pins can be
inserted for better stability without any
vascular compromise. The medial safe
zone could be easily delineated by palpation and appeared safe for routine unilateral external fixation across the medial
hindfoot and ankle.11
Literature review shows only one earlier
reported communited type 1 navicular
fracture, managed by minimal intervention, with pins in talus. We suggest
pin insertion into the calcaneum for the
above-stated advantages.
This technique should be preferred in
communited isolated navicular fractures
(all types), isolated navicular fracture
dislocations, and compound navicular
fractures. For fractures of navicular associated with metatarsal/talus/calcaneum
fractures, an alternative modality of management should be preferred.
We thus conclude that minimal intervention in the form of external fixator
with pins in calcaneum and metatarsals
as an easy and safe modality of fixation
that can achieve optimal stable reduction
and better functional results.

References
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Rymaszewski LA, Robb JE. Mechanism of

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