TARSAL NAVICULAR FRACTURES
Medial Column Keystone | AVN Risk | Sangeorzan Classification | Athletes at Risk
SANGEORZAN CLASSIFICATION (BODY FRACTURES)
Critical Must-Knows
- Precarious blood supply - central third is watershed zone (AVN risk)
- CT scan essential for body fractures - assess articular displacement
- Stress fractures - often missed initially, high index of suspicion in athletes
- Medial column length must be restored - avoid shortening
- 6-8 weeks non-weight-bearing minimum for stress fractures
Examiner's Pearls
- "Blood supply: dorsal and plantar arteries, central zone relatively avascular
- "Sangeorzan Type 2 most common body fracture pattern
- "Stress fractures: central third, sagittal orientation, bone scan/MRI to diagnose
- "Associated injuries: cuboid, cuneiforms, tarsometatarsal joint
- "Malunion leads to planovalgus deformity and midfoot arthritis
Viva Danger Zones
Classic Viva Scenarios:
- High-energy midfoot trauma - systematic assessment of Chopart/Lisfranc complex
- Athlete with vague midfoot pain - navicular stress fracture until proven otherwise
- Displaced navicular body fracture - surgical approach and fixation options
- Post-operative AVN - recognition and salvage options
- Malunion with planovalgus - reconstructive options
Never Say:
- "X-rays are sufficient for surgical planning"
- "Weight-bear as tolerated for stress fractures"
- "Accept any displacement of navicular body fractures"
- "The navicular has good blood supply like other tarsal bones"
At a Glance Table
Navicular Fracture Types: Quick Reference
| Feature | Avulsion | Body | Stress | Tuberosity |
|---|---|---|---|---|
| Frequency | 47% (most common) | 26% | 3% | 24% |
| Mechanism | Capsule avulsion | High-energy axial load | Repetitive loading | PTT avulsion/direct trauma |
| Typical Patient | Any age, low energy | 20-40 years, trauma | Athletes (track/basketball) | Older patients or trauma |
| Key Imaging | X-rays sufficient | CT essential for planning | MRI gold standard | X-rays, CT if large |
| Treatment | Conservative if small | ORIF if displaced over 1mm | NWB 6-8 weeks | ORIF if large/displaced |
| AVN Risk | Very low | 25% (high) | Variable (central worse) | Low |
| Nonunion Risk | Rare | Moderate | High (central location) | Low |
| Return to Activity | 6-8 weeks | 4-6 months | 4-6 months | 8-12 weeks |
| Prognosis | Excellent | Good-Fair (type dependent) | Good if early treatment | Good |
NAVICULAR
Memory Hook:The NAVICULAR is critical for arch support but has fragile blood supply
SANGEORZAN
Memory Hook:Types 1-2-3: Coronal-Oblique-Comminuted (increasing severity)
STRESS
Memory Hook:STRESS fractures need REST - 6-8 weeks non-weight-bearing
Overview
Tarsal Navicular Fractures
The tarsal navicular is a key bone of the midfoot, serving as the keystone of the medial longitudinal arch. Fractures range from minor avulsions to complex body fractures with significant displacement and associated injuries.
Clinical Significance
The navicular's tenuous blood supply makes it susceptible to avascular necrosis (AVN), similar to the scaphoid in the wrist. The central third is a watershed zone with limited vascularity, explaining the high nonunion rate in navicular stress fractures.
Classification by Location:
- Avulsion fractures - Most common (47%)
- Body fractures - Significant injuries, high complication rate
- Stress fractures - Important in athletes
- Tuberosity fractures - Posterior tibial tendon insertion
Epidemiology:
- Rare injuries - navicular fractures comprise 3-5% of all foot fractures
- Body fractures often associated with high-energy trauma
- Stress fractures common in athletes (track and field, basketball, football)
- Male predominance in body fractures
- Peak age: 20-40 years
Anatomy and Blood Supply
Navicular Anatomy - Know Cold for Viva
The navicular bone:
- Location: Keystone of medial longitudinal arch
- Articulations: Talus (proximally), three cuneiforms (distally), cuboid (laterally)
- Insertions: Posterior tibial tendon on tuberosity (major dynamic arch support)
- Shape: Boat-shaped (Latin: navicula = little boat)
Key relationships:
- Part of Chopart (transverse tarsal) joint with talus
- Forms talonavicular joint - critical for hindfoot motion
- Spring ligament supports plantar surface
Blood Supply - Critical Exam Topic
Watershed Zone
The navicular's blood supply is tenuous and similar to the scaphoid:
Arterial Supply:
- Dorsalis pedis artery - dorsal branches
- Medial plantar artery - plantar branches
- These vessels enter from the periphery (medial and lateral)
Watershed Zone:
- The central third of the navicular body is relatively avascular
- Blood supply enters peripherally and does not reach central zone reliably
- This explains high AVN rate in body fractures (25%) and stress fractures
Clinical Implication:
- Central stress fractures have high nonunion rate
- Displaced body fractures disrupt peripheral blood supply
- Open reduction should preserve soft tissue attachments
Functional Anatomy
Medial Column:
- Navicular is the "cornerstone" of the medial column
- Medial column: talus → navicular → medial cuneiform → first metatarsal
- Maintains longitudinal arch height
- Shortening leads to planovalgus deformity
Talonavicular Joint:
- Provides 80% of hindfoot inversion/eversion
- Essential for gait adaptation to uneven surfaces
- Loss of motion significantly affects function
Fracture Types by Location
| Fracture Type | Percentage | Mechanism | Key Features |
|---|---|---|---|
| Avulsion (dorsal lip) | 47% | Talonavicular capsule pull | Low energy, good prognosis |
| Tuberosity | 24% | PTT avulsion or direct trauma | May need fixation if large |
| Body | 26% | High-energy axial load | High complication rate |
| Stress | 3% | Repetitive loading | Athletes, central location |
Classification Systems
Sangeorzan Classification for Body Fractures
The Sangeorzan classification (1989) categorizes navicular body fractures based on fracture pattern and degree of displacement.
Type 1
Coronal plane fracture
- Transverse fracture line
- Dorsal fragment
- No forefoot angulation
- Talonavicular joint intact
- Treatment: ORIF if displaced
- Prognosis: Good if reduced
Type 2
Dorsomedial to plantar-lateral
- Main fracture oblique
- Forefoot displaced dorsally
- Medial column shortened
- Most common pattern
- Treatment: ORIF essential
- Prognosis: Moderate - AVN risk
Type 3
Comminuted
- Central/lateral comminution
- Severe articular damage
- Often high-energy
- Associated injuries common
- Treatment: ORIF + bone graft
- Prognosis: Poor - high AVN/arthritis
Clinical Application:
- Higher type = worse prognosis
- Type 2 most common in clinical practice
- All require CT for surgical planning
These fracture patterns guide treatment decisions and prognosis estimation.
Clinical Assessment
History
Body Fractures:
- High-energy mechanism (MVA, fall from height)
- Axial loading through foot
- Immediate inability to weight-bear
- Associated injuries common (25%)
Stress Fractures:
- Insidious onset of midfoot pain
- Worse with activity, improves with rest
- Often delay in presentation (weeks to months)
- Athletes: recent increase in training intensity
- May recall specific incident when "stress" became "complete"
Examination
Inspection:
- Swelling over dorsum of midfoot
- Ecchymosis (body fractures)
- May appear grossly normal (stress fractures)
- Assess overall foot alignment
Palpation:
- N spot - focal tenderness over navicular body (dorsal, medial, plantar)
- Tuberosity tenderness (posterior tibial tendon insertion)
- Assess adjacent joints (talonavicular, cuneonavicular)
Special Tests:
- Single-leg hop test (stress fractures) - reproduces pain
- Navicular compression test
- Assess posterior tibial tendon function
- Assess hindfoot alignment
The N Spot
Navicular Stress Fracture Sign: The "N spot" is focal tenderness over the proximal dorsal navicular at the junction of the proximal and middle thirds - this is the site of stress fractures in the watershed zone.
Sensitivity: 81% Specificity: 100%
If N spot tenderness present in an athlete with activity-related midfoot pain, pursue advanced imaging even with negative X-rays.
Associated Injuries
Body fractures often occur with:
- Cuboid fractures (nutcracker injury)
- Cuneiform fractures
- Lisfranc injuries
- Talus fractures
- Chopart joint injuries
Assessment:
- Examine entire foot systematically
- Compare to contralateral side
- Document neurovascular status
- Check for compartment syndrome (rare)
Investigations
Imaging Protocol
X-Rays (Standard Foot Series):
- AP, lateral, oblique views
- Body fractures usually visible
- Stress fractures often negative initially (up to 70%)
- Look for subtle cortical break or sclerosis
CT Scan:
- Essential for body fractures - surgical planning
- Assess articular displacement
- Identify comminution pattern
- Evaluate adjacent injuries
- Sangeorzan classification confirmed
MRI:
- Gold standard for stress fractures
- T2 bone marrow edema before cortical break
- 97% sensitivity for stress fractures
- Also evaluates soft tissue injury
Bone Scan:
- Alternative to MRI for stress fractures
- Highly sensitive (early uptake)
- Less specific than MRI
- "Hot" navicular in stress fracture/reaction
Imaging Findings
Body Fractures on CT:
- Fracture pattern (Sangeorzan type)
- Articular step-off measurement
- Comminution assessment
- Medial column length
Stress Fractures on MRI:
- T1: Low signal linear fracture line
- T2/STIR: High signal bone marrow edema
- Location: Central third, sagittal orientation
- Assess for complete vs partial fracture
CT vs MRI
Choose based on fracture type:
- Body fractures: CT for surgical planning
- Stress fractures: MRI for diagnosis and staging
- Both: May be needed for complete evaluation
CT shows bone detail; MRI shows stress reaction before cortical break.
Management Algorithm
Body Fracture Management
Non-Operative Treatment:
Indications:
- Non-displaced fractures (less than 1mm articular step-off)
- No medial column shortening
- Stable fracture pattern
- Patient able to comply with restrictions
Protocol:
- Short leg cast, non-weight-bearing for 6-8 weeks
- X-rays at 2, 4, 6 weeks to assess alignment
- CT at 6 weeks to confirm union
- Transition to weight-bearing boot at 8-10 weeks
- Progressive rehabilitation
Operative Treatment:
Surgical Indications
Absolute indications:
- Displacement greater than 1mm articular step-off
- Medial column shortening
- Unstable fracture pattern (Sangeorzan 2 and 3)
- Open fracture
Relative indications:
- Associated midfoot injuries requiring surgery
- High-demand patient
- Inability to comply with non-weight-bearing
Fixation Options:
- Screws: 3.5mm or 4.0mm cortical lag screws
- K-wires: Temporary or definitive for small fragments
- Mini-fragment plates: 2.0-2.4mm for comminuted fractures
- Bridge plating: Talonavicular to cuneiforms for severe comminution
- External fixation: Severely comminuted with soft tissue compromise
Choice depends on fracture pattern and comminution degree.
FIXATION
Memory Hook:FIXATION principles guide surgical treatment of navicular body fractures
Surgical Technique
Preoperative Planning
Essential Steps:
- Review CT scan for fracture pattern and comminution
- Assess soft tissue envelope - may need staged surgery
- Plan approach based on fracture location
- Prepare for bone grafting if comminution present
Patient Positioning
- Supine with bump under ipsilateral hip
- Thigh tourniquet
- Image intensifier positioned for AP and lateral views
Thorough planning ensures optimal surgical execution.
Complications
Common Complications
Early Complications
- Wound dehiscence
- Infection
- Hardware prominence
- Neurovascular injury
- Compartment syndrome (rare)
Late Complications
- Avascular necrosis (25%)
- Nonunion (especially stress fractures)
- Malunion and planovalgus
- Post-traumatic arthritis
- Chronic pain
Avascular Necrosis
AVN - Major Complication
Risk Factors for AVN:
- Sangeorzan Type 2 and 3 fractures
- Delayed treatment
- Open reduction with extensive soft tissue stripping
- Associated injuries disrupting blood supply
Presentation:
- Persistent pain despite apparent healing
- Progressive collapse on imaging
- Sclerosis followed by fragmentation
Management:
- Early: Protected weight-bearing, may revascularize
- Established AVN with collapse:
- Bone grafting (vascularized or non-vascularized)
- Talonavicular fusion
- Triple arthrodesis (severe cases)
Nonunion
Risk Factors:
- Central stress fractures (watershed zone)
- Inadequate immobilization
- Smoking
- Delayed diagnosis
- Poor blood supply
Treatment:
- Bone stimulator (electrical/ultrasound)
- Surgical fixation with bone grafting
- Consider vascularized bone graft for resistant cases
Malunion
Consequences:
- Medial column shortening → planovalgus deformity
- Talonavicular arthritis
- Altered gait mechanics
- Chronic midfoot pain
Treatment:
- Osteotomy and bone grafting (rarely successful)
- Typically requires talonavicular fusion
- May need triple arthrodesis for severe deformity
Postoperative Care
Immediate Postoperative Period (0-2 weeks)
Hospital Care:
- Posterior splint, strict elevation above heart
- Non-weight-bearing with crutches
- Ice and analgesia
- Neurovascular checks
- DVT prophylaxis if high risk
Discharge Instructions:
- Maintain non-weight-bearing status
- Keep splint dry and clean
- Elevation as much as possible
- Watch for excessive pain, swelling, numbness
Early Phase (2-6 weeks)
Week 2:
- Wound check, suture removal
- Convert to short leg cast or CAM boot
- Continue strict non-weight-bearing
- Begin ankle pumps and toe exercises
Week 4:
- X-rays to assess alignment
- Continue non-weight-bearing
- If stable, may begin gentle ankle ROM in boot
Week 6:
- X-rays to assess early healing
- CT if healing questionable
- Continue non-weight-bearing until bridging callus seen
Mid Phase (6-12 weeks)
Week 8:
- If healing progressing, begin progressive weight-bearing
- Weight-bearing as tolerated in boot
- Physical therapy: ROM, proprioception
- Pool therapy if available
Week 10-12:
- Transition to supportive shoe
- Continue progressive weight-bearing
- Advance strengthening exercises
- Address gait abnormalities
Late Phase (3-6 months)
Months 3-4:
- Full weight-bearing in supportive footwear
- Sport-specific rehabilitation begins
- Impact activities avoided
Months 4-6:
- Gradual return to running (if athlete)
- Sport-specific drills
- Full return to sport if pain-free and full ROM
- Hardware removal if prominent (rarely needed)
Red Flags During Recovery
Concerning Signs
- Persistent pain despite adequate healing time - consider AVN
- Loss of reduction on serial X-rays - may need revision
- No progression of healing at 12 weeks - nonunion risk
- Wound complications - infection risk
- Progressive collapse on imaging - AVN developing
Return to Sport Criteria
Must achieve before clearance:
- Pain-free weight-bearing and walking
- Full or near-full ROM compared to contralateral
- Radiographic union (bridging callus on CT)
- Successful completion of sport-specific drills
- Single-leg hop test equal to contralateral
- Psychological readiness
Typical timeline:
- Office workers: 8-12 weeks
- Manual laborers: 12-16 weeks
- Athletes (non-impact): 4-6 months
- Athletes (impact/running): 6-9 months
Outcomes and Prognosis
Overall Outcomes by Fracture Type
Body Fractures - Operative
Good-Excellent Outcomes: 70-85%
- Type 1 (coronal): 85-90% good outcomes
- Type 2 (oblique): 70-80% good outcomes
- Type 3 (comminuted): 50-60% good outcomes
- AVN rate: 16-25%
- Arthritis rate: 20-30% at 5 years
Stress Fractures
Union Rate: 86-95% with early treatment
- Partial fractures: 95% union
- Complete non-displaced: 85-90% union
- Central location: Higher nonunion rate
- Return to sport: 80-90% of athletes
- Recurrence rate: 10-15%
Prognostic Factors
Good Prognosis Indicators:
- Early diagnosis and treatment (within 2 weeks)
- Anatomic reduction achieved
- Non-displaced or minimally displaced fractures
- Peripheral location (stress fractures)
- Younger age
- Non-smoker
- Good compliance with rehabilitation
Poor Prognosis Indicators:
- Delayed treatment (beyond 3 weeks)
- Sangeorzan Type 3 (comminuted)
- Severe articular damage
- Associated injuries (cuboid, cuneiforms)
- Central stress fracture location
- Smoking
- Poor soft tissue envelope
Functional Outcomes
Return to Work:
- Sedentary work: 8-12 weeks
- Light manual work: 12-16 weeks
- Heavy manual work: 16-24 weeks
Return to Sport:
- Low-impact activities: 3-4 months
- Running/jumping sports: 6-9 months
- Elite athletes: May require 9-12 months
- 10-20% of athletes unable to return to pre-injury level
Long-Term Complications
5-Year Follow-up Data:
- Post-traumatic arthritis: 20-40% (body fractures)
- Chronic pain: 15-25%
- Reduced activity level: 20-30%
- Need for fusion surgery: 5-10%
AVN Natural History:
- Develops within first 2 years post-injury
- May revascularize in 30% of cases
- Progressive collapse in 50-70% if severe
- Often requires salvage fusion procedures
Quality of Life
Patient Counseling
Key messages for patients:
-
Body fractures: "Most patients do well with surgery, but there is a 1 in 4 chance of blood supply problems (AVN) and a 1 in 5 chance of arthritis developing over time."
-
Stress fractures: "With strict rest for 6-8 weeks, 9 out of 10 athletes heal and return to sport. The bone heals slowly because of limited blood supply."
-
Time off sport: "Expect 6-9 months before full return to impact sports. Rushing increases risk of re-fracture or failure to heal."
Evidence Base
Sangeorzan Classification (1989)
- Classification of 21 navicular body fractures into 3 types based on fracture pattern. Type 2 most common. Higher type associated with worse outcomes. 25% AVN rate overall.
Navicular Stress Fractures - Khan Review
- 22 athletes with navicular stress fractures. 86% union rate with early treatment (non-weight-bearing 6-8 weeks). Delayed treatment had significantly worse outcomes.
Surgical Treatment of Navicular Body Fractures
- 25 displaced body fractures treated with ORIF. 76% good/excellent outcomes. Type 3 fractures had significantly worse results. AVN in 16%.
CT-Based Assessment of Navicular Fractures
- CT identified additional fracture lines in 67% of cases and changed surgical plan in 43%. Better assessment of articular involvement.
Return to Sport After Navicular Stress Fractures
- 10 athletes with navicular stress fractures. Those treated with cast immobilization and non-weight-bearing had better outcomes than those with activity restriction alone.
Viva Scenarios
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
"A 25-year-old track athlete presents with 6 weeks of worsening midfoot pain during running. The pain localizes to the dorsum of the foot over the navicular. X-rays appear normal."
Differential Diagnosis:
- Navicular stress fracture - most likely given history and location
- Midfoot sprain/ligament injury
- Posterior tibial tendinopathy
- Stress reaction (pre-fracture)
- Extensor tendinopathy
Clinical Assessment:
- Test for N spot tenderness - dorsal navicular at proximal-middle third junction
- Single-leg hop test - positive if reproduces pain
- Assess posterior tibial tendon function
- Examine entire midfoot
Imaging:
- X-rays often negative in early stress fractures (up to 70%)
- MRI is investigation of choice - shows bone marrow edema before cortical break
- CT if MRI confirms fracture - assess displacement
Management if Stress Fracture Confirmed:
- Strict non-weight-bearing for 6-8 weeks - critical for healing
- Short leg cast or CAM boot
- Repeat imaging at 6 weeks to confirm healing
- Gradual return to activity over 4-6 weeks
- Address training errors and biomechanics
"A 35-year-old man is brought to ED after a motorcycle accident. He has a swollen, deformed midfoot. X-rays show a displaced navicular body fracture with associated cuboid fracture. CT shows a Sangeorzan Type 2 pattern with 5mm of medial column shortening."
Preoperative Assessment:
- ATLS assessment - exclude other injuries
- Neurovascular exam of foot
- Assess soft tissue envelope - may need staged surgery
- CT review: Sangeorzan Type 2, medial column shortening, cuboid involvement
Surgical Planning:
- Timing: Ideally within 2 weeks if soft tissues allow
- Approach: Dorsomedial for navicular, separate lateral approach for cuboid
- Goals: Restore medial column length, anatomic articular reduction
Surgical Technique:
- Dorsomedial incision between tibialis anterior and EHL
- Protect dorsalis pedis artery and deep peroneal nerve
- Identify and expose fracture fragments
- Reduce medial column length with distraction
- Temporary K-wire fixation
- Definitive fixation: 3.5mm lag screws or mini-fragment plate
- Address cuboid through lateral approach
- Intraoperative fluoroscopy to confirm reduction
Postoperative:
- Posterior splint, strict non-weight-bearing
- 6-8 weeks NWB, then progressive weight-bearing
- Monitor for AVN - common in Type 2 fractures
"A 30-year-old athlete is 4 months post-operatively from navicular body fracture ORIF. She has persistent midfoot pain. X-rays show sclerosis and partial collapse of the navicular. What is your diagnosis and management?"
Diagnosis:
- Avascular necrosis (AVN) of the navicular
- Incidence: 25% in body fractures, higher in Type 2/3
- Confirm with MRI: T1 hypointensity, lack of enhancement
Classification and Staging:
- Stage 1: Normal X-rays, MRI changes only
- Stage 2: Sclerosis without collapse
- Stage 3: Partial collapse, subchondral fracture
- Stage 4: Complete collapse, secondary arthritis
Management Options:
Early AVN (Stage 1-2):
- Protected weight-bearing - may allow revascularization
- Core decompression (limited evidence)
- Observation with serial imaging
Established AVN with Collapse (Stage 3-4):
- Bone grafting: Non-vascularized or vascularized (medial femoral condyle)
- Talonavicular fusion: If articular destruction, provides pain relief
- Triple arthrodesis: Severe deformity, pantalar involvement
Counseling:
- Prognosis guarded for return to high-level sport
- May require activity modification long-term
- Fusion procedures eliminate talonavicular motion
MCQ Practice Points
High-Yield Facts for MCQs
Stress Fracture Diagnosis
Q: A young athlete has vague midfoot pain but normal X-rays. What is the next step? A: MRI - X-rays are negative in 70% of early stress fractures. MRI is the gold standard (97% sensitive) showing bone marrow edema before a cortical break appears.
N-Spot Tenderness
Q: What is the 'N-Spot' and what does it signify? A: Dorsal Navicular Tenderness - Located at the junction of the proximal and middle thirds. It is 81% sensitive and 100% specific for navicular stress fractures.
Watershed Zone
Q: Why do central navicular fractures have a high nonunion rate? A: Poor Vascularity - The central third is a watershed zone between the dorsalis pedis and medial plantar arterial supplies. This tenuous blood supply impairs healing.
Sangeorzan Classification
Q: Which Sangeorzan type is the most common? A: Type 2 - The fracture line runs from dorsomedial to plantar-lateral. It results in forefoot medialization and dorsal displacement, requiring ORIF to restore length.
Treatment of Stress Fractures
Q: What is the critical management principle for navicular stress fractures? A: Variables: Strict NWB vs Surgery - Conservative management requires 6-8 weeks of strict non-weight-bearing in a cast. Weight-bearing leads to nonunion or recurrence.
Surgical Threshold
Q: When is surgery indicated for a navicular body fracture? A: Greater than 1mm Displacement - Any articular step-off greater than 1mm or loss of medial column length warrants ORIF to prevent post-traumatic arthritis and deformity.
Australian Context
Australian Epidemiology
Navicular fractures in Australia show similar patterns to international data, but with some unique considerations:
Sports-Related Injuries:
- Australian Rules Football (AFL) players have increased stress fracture risk due to high running volumes and repeated jumping
- Rugby Union and Rugby League also see navicular stress fractures in forwards and backs
- Track and field athletes (particularly middle-distance runners) represent significant proportion of stress fracture cases
- Cricket fast bowlers occasionally present with navicular stress fractures
Workplace Injuries:
- Construction and mining industries account for high-energy body fractures
- WorkCover claims for navicular fractures typically require 12-24 weeks off work for manual laborers
- Return-to-work programs should emphasize graduated loading
Australian Guidelines and Resources
Imaging:
- MRI is widely available through public and private systems for suspected stress fractures
- Medicare rebate available for MRI foot when appropriate clinical indication documented
- CT scans for surgical planning are standard of care in major trauma centers
Treatment Access:
- Operative treatment for displaced navicular fractures available at all major trauma centers
- Orthopedic foot and ankle specialists in major cities (Sydney, Melbourne, Brisbane, Perth, Adelaide)
- Regional centers may require transfer for complex cases
Rehabilitation:
- Sports medicine physicians and physiotherapists experienced in stress fracture management widely available
- Australian Institute of Sport (AIS) protocols for return to running applicable
- Bone density screening recommended for recurrent stress fractures (osteoporosis considerations)
Follow-Up and Outcomes
Public vs Private:
- Public system follow-up typically at 2, 6, 12 weeks post-surgery
- Private practice may offer more frequent review
- CT at 6-8 weeks standard for assessing union in body fractures
Return to Work:
- WorkCover may fund extended physiotherapy for manual workers
- Graduated return-to-work programs recommended for heavy laborers
- Desk-based workers typically return at 8-10 weeks with fracture boot
Considerations for Australian Practitioners
Indigenous Australians:
- Higher rates of diabetes may affect fracture healing
- Access to care in remote communities may be limited
- Telemedicine follow-up increasingly used for remote patients
Sports Medicine:
- AFL and NRL clubs have dedicated medical teams - early referral for suspected stress fractures
- State sports institutes provide high-level rehabilitation
- Return to elite sport decisions often involve multi-disciplinary teams