Working Diagnosis:
Bipartite navicular with subacute fracture concerning for developing osteonecrosis

Treatment:
Initially, the athlete was managed non-operatively: non-weight-bearing; immobilized in a walking boot.

Surgical management included debridement of sclerotic regions along the fracture site, placement of the bone auto-graft, and fixation. No arthrodesis was performed.

Outcome:
12 weeks post-op, the athlete has progressed to running, limited jumping/foot contacts, and baseball activities.

Post-Op Radiograph Case Photo #9 Left Foot: Navicular fixation with screws and fracture plate.

We expect the athlete will return to baseball at his previous level of functioning by this summer.

Author's Comments:
A bipartite navicular can cause pes planus and promote osteoarthritic change of the talonavicular joint. If non-operative management fails to treat arthritis, arthrodesis can be considered with potential for restricted midtarsal motion. Navicular fractures commonly result from trauma or chronic overload, and are susceptible to osteonecrosis and arthrosis of surrounding joints.

Editor's Comments:
The navicular bone is the keystone of the medial column of the foot and it bears the the majority of the load when weight-bearing. Weight-bearing radiographs can help to rule out unstable injuries of the midtarsal joint complex. Advanced imaging can also help rule out soft-tissue injuries that can present with fractures.

Accessory naviculars are the most common accessory ossification center in the foot. They appear during adolescence and most are found incidentally and are asymptomatic. Most common issues with accessory naviculars include traumatic pain, chronic irritation/ overuse, and as the posterior tibialis tendon inserts on the navicular athletes may present with posterior tibialis pain and dysfunction. Stress fractures of the navicular are often not visible on plain films and are under diagnosed. Delay to diagnosis is common. Navicular stress fractures are at risk for avascular necrosis and thus considered a high risk stress fracture. Complications to be aware of including non-union and delay of union.

References:
1. Ramadorai U, Beuchel M, Sangeorzan. Fractures and dislocations of the tarsal navicular: a review. AAOS. 2016: 379-389.
2. Coulibaly M, Jones C, Sietsema D, et al. Results and complications of operative and non-operative navicular fracture treatment. Injury, Int J Care Injured. 2015: 1669-1677.
3. Tanaka Y, Yoshinori T, Omokawa S, et al. Crank-shaped arthrodesis for a flatfoot with a bipartite navicular: a case report. Foot and Ankle Int. 2006: 734-737.
4. Brukner P, Bradshaw C, Khan K, et al. Stress fractures: a review of 180 cases. CJSM. 1996: 85-89.

Acknowledgments:
Shawn Hanlon, ATC at Lincoln University; Brandon Olaya, ATC at Lincoln University; Heather Wolfe, ATC at Lincoln University

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