Open reduction and internal fixation of navicular body, tuberosity and stress fractures · advanced
- The navicular is the keystone of the medial longitudinal arch and the transverse arch — interposed between the talar head and the three cuneiforms. Loss of navicular integrity shortens the medial column and collapses the arch, so reduction must restore talonavicular and naviculocuneiform joint congruity and column length, not just fracture-line apposition.
- The central third of the navicular is a vascular watershed zone. Branches enter at the medial tuberosity and the dorsal and lateral surfaces but converge centrally, leaving the middle relatively avascular. This is where stress fractures originate and why displaced fractures and stress fractures through the centre are prone to delayed union, nonunion and avascular necrosis.
- Body fractures are classified by Sangeorzan (Types I to III); stress fractures by Saxena (Types I to III). ORIF is indicated for displaced body fractures with articular incongruity (step-off greater than 2 mm), arch collapse, or comminution, and for complete (Saxena III) stress fractures.
- The standard fixation is a dorsal or dorsomedial approach between the tibialis anterior and extensor hallucis longus tendons. The dorsalis pedis artery and deep peroneal nerve lie between EHL and EDL and cross the proximal navicular; the medial dorsal cutaneous branch of the superficial peroneal nerve runs subcutaneously across the dorsum — both must be identified and protected.
When & Why
Indication. ORIF is reserved for navicular fractures where displacement, articular incongruity, or instability threatens the medial column and the two articular surfaces it carries. Absolute indications
- Displaced intra-articular body fracture with articular step-off greater than 2 mm on the talonavicular or naviculocuneiform surface
- Open navicular fracture — urgent debridement and skeletal stabilisation
- Fracture-dislocation of the midfoot (Chopart involvement) with navicular displacement
- Displaced complete stress fracture (Saxena Type III) through the plantar cortex, or any complete stress fracture that has failed a trial of strict non-weight-bearing
- Large displaced tuberosity avulsion (greater than 5 mm) with posterior tibial tendon dysfunction, or symptomatic nonunion Relative indications
- Sangeorzan Type II body fracture with lesser but functionally significant displacement in a high-demand patient
- Comminuted Type III fracture where primary stable fixation is preferred over prolonged casting
- Athlete with a complete (Saxena III) stress fracture requesting the earliest reliable return to sport, after counselling on operative versus non-operative trade-offs
- Symptomatic painful accessory navicular (Type II) refractory to non-operative care, with or without avulsion of the accessory fragment Contraindications
- Absolute: medically unfit for anaesthesia; active deep infection at the surgical site (other than an open fracture requiring debridement); a non-displaced stress or body fracture that will predictably unite with strict non-weight-bearing — surgery adds risk without benefit.
- Relative: peripheral vascular disease or diabetes with neuropathy (elevated wound and nonunion risk — optimise and counsel); severe comminution where fixation is non-viable (consider external fixation or primary arthrodesis of the involved column); tobacco use (elevated nonunion risk — advise cessation before elective fixation). Three patterns change the operative plan and deserve specific thought before scrubbing:
Insidious dorsal midfoot pain in a runner or jumper. Plain radiographs are frequently normal — request CT (fracture line) or MRI (stress response). Partial fractures (Saxena I and II) are managed with strict non-weight-bearing; complete (Type III) fractures warrant fixation. Correct training-load, footwear, biomechanical and relative energy-deficiency factors before return, or recurrence is likely.
Image the contralateral foot. An accessory navicular (os tibiale externum) is bilateral, smooth, corticated and rounded at the posterior tibial tendon insertion, whereas an acute avulsion is sharp, unilateral and tender. The operations differ — a symptomatic accessory navicular is excised with tibialis posterior advancement (Kidner), not fixed like a fresh fracture.
The thin dorsal skin and contused envelope govern timing. Span the medial column with temporary external fixation, wait for the wrinkle sign to return (typically 5 to 10 days), then perform definitive ORIF. If the navicular is unreconstructable, primary arthrodesis of the destroyed joint is preferable to a collapsed painful midfoot.
Consent specifically on wound complications (dorsal thin skin), hardware prominence requiring later removal, nonunion of a central or stress fracture, post-traumatic arthritis of the talonavicular or naviculocuneiform joint possibly requiring later arthrodesis, and the prolonged 6-week non-weight-bearing period. Setup. Supine on a radiolucent table with a small ipsilateral bump under the hip to control external rotation and bring the dorsum uppermost. General or regional (popliteal or adductor canal) anaesthesia with a thigh tourniquet at 250 to 300 mmHg for a bloodless dorsal field. Before draping, examine and document the dorsalis pedis and posterior tibial pulses and the cutaneous sensation on the dorsum and plantar surfaces, and confirm reduction targets on intra-operative fluoroscopy (AP, oblique and lateral).
The triggers to operate are an articular step-off greater than 2 mm, collapse or shortening of the medial column, an open fracture, or a fracture-dislocation. A complete stress fracture through the plantar cortex (Saxena III) is high-risk and warrants fixation. A non-displaced fracture that will unite with strict non-weight-bearing is best treated without surgery.
A navicular stress fracture is frequently occult on plain radiographs. In an athlete with dorsal midfoot pain and focal tenderness over the dorsal central navicular (the N spot), request CT to show a fracture line or MRI for stress response. Do not discharge on a normal film alone.
The Operation
The goal is to expose the navicular through a dorsomedial approach between the tibialis anterior and extensor hallucis longus, protect the dorsalis pedis artery, deep peroneal nerve and medial dorsal cutaneous nerve throughout, anatomically restore BOTH articular surfaces and medial column length, and stabilise the construct so the central avascular zone is protected until union. The exposure is laid out inline as the first steps — it is the heart of the operation.
Operative sequence
- Supine on a radiolucent table with an ipsilateral hip bump to bring the dorsum of the foot uppermost; the foot rests on a folded sheet or radiolucent support.
- General or regional anaesthesia; thigh tourniquet at 250 to 300 mmHg for a bloodless dorsal field.
- Examine and document the dorsalis pedis and posterior tibial pulses and dorsal and plantar sensation (baseline). Confirm reduction targets on AP, oblique and lateral fluoroscopy before draping.
- Palpate the navicular tuberosity on the medial border (about 2 to 3 cm distal and plantar to the medial malleolus, at the posterior tibial insertion), the N spot (the dorsal central prominence — point of maximal tenderness in a stress fracture), the talonavicular joint just proximal to the navicular, and the tibialis anterior tendon (the obvious subcutaneous cable crossing to the medial cuneiform).
- Plan a dorsomedial longitudinal incision centred over the navicular, from just proximal to the talonavicular joint to the naviculocuneiform joint, in the interval between the tibialis anterior tendon (medial) and the extensor hallucis longus tendon (lateral), or just dorsal to the tibialis anterior.
- Make the incision sharply down to but not through the superficial nerves; the dorsal skin here is thin and unforgiving.
- Identify the medial dorsal cutaneous branch of the superficial peroneal nerve — it lies immediately subcutaneously across the field and is the structure most often injured. Sling it with a vessel loop and develop flaps in a single deep subcutaneous plane rather than two thin skin flaps.
- Incise the extensor retinaculum and dorsal capsule in line with the skin, staying medial to the EHL tendon.
- Gently retract the EHL laterally, carrying the dorsalis pedis artery and deep peroneal nerve with it on its deep surface. A dorsomedial approach kept between tibialis anterior and EHL stays medial to this bundle; straying lateral to EHL endangers the artery.
- Open the dorsal capsule to expose the navicular body and the proximal articular surfaces of BOTH the talonavicular and naviculocuneiform joints.
- Irrigate to clear haematoma; inspect the fracture pattern, comminution, fragment size and vascularity, and the integrity of both articular surfaces. Provisionally reduce the fragments and judge the extent of any bone defect needing graft.
- The reduction is judged by the congruity of BOTH surfaces and by restoration of medial column length, confirmed on the lateral fluoroscan — a fracture line that looks reduced but leaves a talonavicular step-off is a failed reduction.
- For a large dorsal fragment (Sangeorzan I), reduce it anatomically onto the plantar piece. For a dorsomedial shear (Sangeorzan II), restore the joint surface and correct forefoot adduction by lengthening the medial column. For comminuted patterns (Sangeorzan III), reconstruct the joint surface fragment by fragment, accepting that the construct will need buttress support.
- Use the talonavicular and naviculocuneiform articular surfaces as templates — reconstructing the navicular to fit the talar head and cuneiforms restores the keystone position. Hold each fragment with fine K-wires and check arch height on the lateral image before committing to screws.
- Large fragments — one or two 3.5 mm cortical lag screws (2.7 mm for smaller fragments), glide hole in the near fragment and thread hole in the far; countersink the head in the thin dorsal cortex to avoid prominence. Direct screws dorsal-to-plantar, perpendicular to the fracture line, keeping them short of or just engaging the plantar cortex.
- Comminuted patterns — a lag screw alone will shorten the column. Add a mini-fragment (2.0 to 2.7 mm) neutralisation or bridge plate along the dorsal or dorsomedial navicular; in highly comminuted injuries a plate may temporarily span the talonavicular or naviculocuneiform joint, with planned removal once healed.
- Tuberosity avulsion — a small lag screw or tension band capturing the posterior tibial tendon insertion; repair the tendon to bone if the fragment is small.
- Stress fracture (Saxena III) — percutaneous or mini-open placement of one or two compression screws across the central fracture line, without stripping the dorsal supply.
- For cavitary or comminuted defects in the central body (common in Sangeorzan III), back-fill with autogenous cancellous bone graft from the medial calcaneus or distal tibia, or allograft, to support the reduced articular surface and encourage union in the avascular centre.
- Release the tourniquet, achieve haemostasis, and close the capsule, extensor retinaculum and skin in layers over the protected nerves.
- Apply a well-padded posterior splint holding the foot plantigrade. Confirm final reduction and hardware position on AP, oblique and lateral fluoroscopy and save the images.
On the dorsum of the foot the dorsalis pedis artery and deep peroneal nerve run together between the extensor hallucis longus and extensor digitorum longus tendons, crossing the proximal navicular and the talonavicular joint. Any dorsal incision that strays lateral to the EHL threatens this bundle. Palpate (or Doppler) the dorsalis pedis pre-operatively and document it; keep the dorsomedial incision between the tibialis anterior and EHL, stay medial to the bundle, and protect it with a broad retractor on the EHL. If injured, repair primarily where possible and confirm adequate collateral inflow from the posterior tibial system first.
The medial dorsal cutaneous branch of the superficial peroneal nerve lies immediately deep to the skin across the navicular region and is easily transected when raising flaps. Identify it in every dorsal flap, make the skin incision sharply down to it, and develop flaps in the deep subcutaneous plane deep to it. A neuroma of this nerve is a miserable, hard-to-treat complication.
Before placing a screw, look at both joints — the talonavicular proximally and the naviculocuneiform distally. The reduction is judged by the congruity of BOTH surfaces and by restoration of medial column length and arch height on the lateral fluoroscan, not by fracture-line apposition alone.
A lag screw across a comminuted zone without a neutralisation or bridge plate shortens the medial column and collapses the arch. Always add a dorsomedial mini-fragment bridge or neutralisation plate for comminution, and back-fill the central defect with bone graft.
- Implant
- One or two 3.5 mm lag screws dorsal-to-plantar
- Key point
- Countersink the head; restore the talonavicular joint
- Implant
- Lag screw plus mini-fragment neutralisation plate
- Key point
- Correct forefoot adduction; restore column length
- Implant
- Bridge mini-fragment plate plus bone graft, with temporary joint spanning if needed
- Key point
- Prioritise articular reconstruction over anatomic fragment position
- Implant
- One or two compression screws perpendicular to the line
- Key point
- Minimal exposure; preserve the dorsal blood supply
- Implant
- Lag screw or tension band
- Key point
- Repair the posterior tibial tendon to bone if the fragment is small
Aftercare & Complications
Rehabilitation | Phase | Timing | Immobilisation | Weight-bearing / activity | |-------|--------|----------------|---------------------------| | 1 | 0 to 2 weeks | Posterior splint, strict non-weight-bearing, elevation | Wound check at 10 to 14 days | | 2 | 2 to 6 weeks | Non-removable cast or CAM boot, strictly non-weight-bearing | Protect the central avascular zone | | 3 | 6 to 10 weeks | CAM boot, graduated weight-bearing as union progresses | Gentle active foot and ankle range of motion out of the boot | | 4 | 10 to 12 weeks and beyond | Wean the boot to normal footwear | Proprioceptive and strengthening rehabilitation | Imaging surveillance: radiographs (AP, oblique, lateral, weight-bearing when able) at 2, 6 and 10 to 12 weeks. For stress fractures and comminuted body fractures, a CT at 8 to 12 weeks confirms bridging before unrestricted loading — plain films underestimate healing. Return to function
- Desk work — 1 to 2 weeks.
- Weight-bearing work — 10 to 12 weeks.
- Driving — once full, pain-free weight-bearing and adequate control (typically 8 to 10 weeks for the right foot).
- Running sports — 4 to 6 months, after CT-confirmed union and a completed rehabilitation programme.
Non-weight-bearing protection for a minimum of 6 weeks is mandatory for non-operative stress fractures and after ORIF alike. Premature loading of the central avascular zone is the commonest cause of nonunion. Do not discharge an athlete on a normal radiograph, and do not allow return to running on symptom resolution alone — require CT evidence of bridging.
Complications
- Incidence and setting
- Higher after high-energy displaced body fractures and central stress fractures; reflects the watershed blood supply
- Recognition
- Progressive dorsal midfoot pain, arch collapse, sclerosis and fragmentation on CT/MRI
- Prevention and management
- Prevention: minimise dorsal stripping, preserve capsular attachments, strict NWB. Management: protected weight-bearing; reconstructive arthrodesis of the involved column if collapse and pain progress
- Incidence and setting
- The classical failure of navicular stress fractures; raised by premature weight-bearing, smoking and complete (Saxena III) patterns
- Recognition
- Persistent dorsal midfoot pain beyond the expected healing window; CT shows a persistent fracture line without bridging
- Prevention and management
- Prevention: strict 6-week NWB, monitor with CT, do not discharge on a normal radiograph. Management: open bone-grafting and compression screw fixation; address smoking and nutrition
- Incidence and setting
- Follows articular step-off, comminution or AVN; the talonavicular joint is most functionally significant
- Recognition
- Activity-related dorsal midfoot pain, stiffness, effusion; joint-space narrowing and sclerosis on weight-bearing radiographs
- Prevention and management
- Prevention: anatomic restoration of both articular surfaces at the index operation. Management: non-operative first (orthosis, NSAIDs, activity modification); arthrodesis of the arthritic joint for refractory pain
- Incidence and setting
- Follows shortening of the medial column from a lag screw across comminution or an under-reduced Type III fracture
- Recognition
- Loss of arch height, medial midfoot pain, difficulty on push-off; lateral view shows column shortening
- Prevention and management
- Prevention: judge reduction by column length on lateral fluoroscopy; add a neutralisation or bridge plate for comminution. Management: accommodative orthosis for mild cases; reconstructive osteotomy or arthrodesis for symptomatic collapse
- Incidence and setting
- Common — dorsal screws and plates sit under thin dorsal skin
- Recognition
- Tender palpable hardware, pain on shoe wear, overlying erythema
- Prevention and management
- Prevention: countersink screw heads, use low-profile mini-fragment plates, place hardware off the most superficial point. Management: hardware removal after union confirmed on CT
- Incidence and setting
- From transection of the medial dorsal cutaneous branch during a dorsal or dorsomedial incision
- Recognition
- Numbness or dysaesthesia in the dorsal forefoot distribution; positive Tinel over a tender lump at the scar
- Prevention and management
- Prevention: identify and protect the nerve in every dorsal flap. Management: desensitisation and neuromodulatory medication; excision and burial of a symptomatic neuroma into muscle or bone if refractory
- Incidence and setting
- Elevated with thin dorsal skin, diabetes, peripheral vascular disease, smoking and open fractures
- Recognition
- Erythema, dehiscence, drainage; CRP and white-cell rise; deep involvement threatens hardware and joint
- Prevention and management
- Prevention: full-thickness flaps, meticulous handling, glycaemic and vascular optimisation. Management: wound care and oral antibiotics for superficial; surgical debridement, cultures and intravenous antibiotics for deep
Viva & Exam Focus
NAVICULARNAVICULAR — anatomy, blood supply and operative principles
STRESSSTRESS — navicular stress fracture assessment
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 22-year-old elite middle-distance runner presents with six weeks of insidious dorsal midfoot pain that is worse with running and eased by rest. Plain radiographs are normal. On examination there is focal tenderness over the dorsal central navicular. A CT confirms a complete navicular stress fracture through the central third extending to the plantar cortex, without displacement. How do you manage her?”
“A 40-year-old man sustains a high-energy midfoot injury in a motorcycle crash. CT shows a comminuted displaced fracture of the navicular body with disruption of the talonavicular and naviculocuneiform articular surfaces and shortening of the medial column — a Sangeorzan Type III pattern. The overlying skin is intact but badly contused. Talk me through your operative plan.”
“A 16-year-old boy presents after a fall with acute medial midfoot pain. A radiograph shows a separate ossicle at the navicular tuberosity. His mother asks whether he has broken a bone. How do you decide between an acute avulsion fracture and an accessory navicular, and how does it change management?”
Background & Evidence
Position and articulations. The tarsal navicular is a crescent-shaped bone on the medial side of the midfoot, interposed between the talar head proximally and the three cuneiforms distally. Its concave proximal face articulates with the rounded talar head, forming the ball-and-socket talonavicular joint — which, with the calcaneocuboid joint, makes up the transverse tarsal (Chopart) joint. Its convex distal face articulates with the medial, intermediate and lateral cuneiforms at the three naviculocuneiform joints; laterally it may articulate with the cuboid. The prominent navicular tuberosity projects inferiorly and medially and receives the principal insertion of the posterior tibial tendon. The keystone concept. The navicular is the keystone of both the medial longitudinal arch and the transverse arch, sitting at the apex of the medial column and transferring load from hindfoot to forefoot. Disruption of its position shortens the medial column and lowers the arch — the anatomical basis for post-traumatic flatfoot after malreduced navicular fractures. Blood supply — the watershed zone. Dorsal branches of the dorsalis pedis artery (the medial tarsal and arcuate branches) enter the dorsal surface; medial branches of the posterior tibial artery, via medial plantar branches, enter at the tuberosity. These dorsal, lateral and medial inputs converge toward the centre but leave the central third relatively avascular — a watershed zone. This is where the repetitive compressive load of gait concentrates in athletes, which is why navicular stress fractures originate in the central third and propagate toward the plantar cortex, and why central fractures heal reluctantly. An anatomic reduction that protects soft-tissue attachments and a prolonged period of non-weight-bearing are mandatory. Dorsal neurovascular anatomy — the operative hazards. The dorsalis pedis artery and deep peroneal nerve run together on the dorsum between the EHL and EDL tendons, crossing the proximal navicular and the talonavicular joint, lying lateral to the EHL, with the artery continuing as the first dorsal metatarsal and deep plantar branch into the first webspace. A dorsomedial approach kept between tibialis anterior and EHL stays medial to this bundle. The superficial peroneal nerve divides into the medial dorsal cutaneous and intermediate dorsal cutaneous branches, which run subcutaneously across the dorsum; the medial dorsal cutaneous nerve crosses the navicular region just beneath the skin and is the structure most at risk from a dorsal incision. Tendon and ligament attachments | Structure | Attachment | Significance | |-----------|-----------|--------------| | Posterior tibial tendon | Navicular tuberosity (principal insertion, with slips to all cuneiforms, cuboid and metatarsal bases) | Avulses the tuberosity in forced eversion against a contracting tibialis posterior | | Tibialis anterior tendon | Passes across the medial navicular to the medial cuneiform and first metatarsal | Landmark for the dorsomedial approach — the incision lies just lateral or dorsal to it | | Dorsal talonavicular ligament | Dorsal capsule of the TN joint | Part of the Chopart capsule; preserved where possible | | Spring (plantar calcaneonavicular) ligament | Sustentaculum tali to the plantar navicular | Supports the talar head; disruption contributes to flatfoot | Classification — Sangeorzan body fractures (the operative planning framework for displaced intra-articular body fractures):
- Fracture pattern
- Coronal cleavage fracture with a large dorsal fragment (greater than 50 percent of the bone)
- Forefoot alignment
- Forefoot aligned, no displacement
- Typical management
- ORIF if displaced; lag-screw fixation of the dorsal fragment to the plantar piece
- Fracture pattern
- Dorsomedial fragment sheared off; line runs dorsomedial to plantarlateral — the commonest pattern
- Forefoot alignment
- Forefoot adducted through the fracture
- Typical management
- ORIF to restore joint congruity and column alignment; lag or minifragment fixation
- Fracture pattern
- Comminuted fracture with severe joint disruption
- Forefoot alignment
- Forefoot displaced laterally or medially
- Typical management
- ORIF with bone graft and bridge plating; consider spanning the TN or NC joint, or primary arthrodesis if unreconstructable
Classification — Saxena stress fractures (stratifies navicular stress fractures by completeness):
- Description
- Dorsal cortical break only (partial)
- Risk
- Lower
- Management
- Non-weight-bearing cast or boot for 6 weeks; close radiographic or CT follow-up
- Description
- Fracture propagates into the navicular body but incomplete
- Risk
- Intermediate
- Management
- Strict non-weight-bearing for 6 weeks; fixation if it fails to progress or in a high-demand athlete
- Description
- Complete fracture through to the plantar cortex, with or without displacement
- Risk
- High — nonunion-prone
- Management
- Surgical fixation (percutaneous or open lag screw); displaced complete fractures need ORIF
Operative versus non-operative thresholds
- Non-operative
- NWB cast or boot for 6 weeks, then graduated weight-bearing
- Operative threshold
- Secondary displacement or articular step-off greater than 2 mm
- Non-operative
- Not appropriate if displaced
- Operative threshold
- Displacement of the dorsal fragment, joint incongruity
- Non-operative
- Rarely acceptable
- Operative threshold
- Operative — restore congruity and column
- Non-operative
- Not appropriate
- Operative threshold
- Operative — ORIF, bone graft, bridge plate, with arthrodesis if needed
- Non-operative
- NWB 6 weeks, CT or MRI follow-up
- Operative threshold
- Failure to progress or propagation
- Non-operative
- High nonunion risk
- Operative threshold
- Operative fixation
- Non-operative
- Boot or cast if less than 5 mm displaced
- Operative threshold
- Greater than 5 mm displacement or symptomatic nonunion
References
Displaced intraarticular fractures of the tarsal navicular
- Landmark series of displaced intra-articular navicular body fractures that introduced the Sangeorzan Types I to III classification
- Established open reduction and internal fixation as the principle for displaced fractures with articular incongruity
- Showed that anatomic restoration of the talonavicular and naviculocuneiform surfaces predicts outcome
Results of treatment of 22 navicular stress fractures and a new proposed classification
- Proposed the Saxena classification: Type I dorsal cortical, Type II propagating into the body, Type III complete to the plantar cortex
- Reported outcomes of 22 athletic navicular stress fractures managed operatively and non-operatively
- Found that complete (Type III) fractures took longer to heal and benefited from surgical fixation
Stress fractures of the tarsal navicular: a retrospective review of twenty-one cases
- Classic description of tarsal navicular stress fractures in 21 patients, predominantly athletes
- Localised the stress fracture to the central third of the navicular, the relatively avascular watershed zone
- Emphasised that plain radiographs are frequently normal and that tomography (now CT) is required for diagnosis
Outcome of conservative and surgical management of navicular stress fracture in athletes
- Reviewed outcomes of navicular stress fractures in athletes managed conservatively versus surgically
- Reported prolonged time to return to sport with non-operative management and a meaningful nonunion rate
- Suggested that surgical fixation may expedite union and return to sport for complete fractures
Injuries of the midtarsal joint
- Classic review of midtarsal (Chopart) injuries detailing the patterns of ligamentous and bony failure
- Highlighted the navicular as the structural keystone of the medial longitudinal arch
- Established that loss of navicular integrity leads to arch collapse and midfoot deformity