Working Diagnosis:
Complete Displaced tarsal-navicular fracture, likely preceded by occult stress fracture.

Treatment:
He was referred to an orthopedic surgery. He underwent open reduction with internal fixation of the tarsal-navicular bone requiring bone graft harvested from the right calcaneus. The surgeon stated that the fracture site exhibited evidence of chronic callous and sclerotic bony changes of long-standing duration.

Outcome:
He was casted for 6 weeks. He was then placed in a non-weight-bearing boot for 3 months. Range-of-motion physical therapy was started at 2 months post-operatively. He was bearing weight at 3 months and gradually increased activity. He is scheduled for follow-up with the surgeon just before Spring football practices start in April 2015.
Although the patient is healing and progressing well, a return to his previous level of football ability remains highly questionable.

Author's Comments:
Arriving at an anatomically specific diagnosis of a foot or ankle injury is essential for proper decision making.
Advanced imaging is often required to make an accurate diagnosis of such injuries.
Corticosteroid injections of the foot and ankle, although commonly done, should be strongly reconsidered in the absence of a specific, confirmed diagnosis, as it may mask pain that leads to further, and sometimes catastrophic injury.

Editor's Comments:
Fractures of the navicular are uncommon and may result from eversion, hyperextension, direct trauma, or extreme flexion with rotation, and they are often associated with other injuries of the mid-tarsal joint. Navicular fractures are commonly missed on plain films and often require CT and MRI for diagnosis. Non-displaced body fractures and avulsion fractures can be treated conservatively in a short-leg weight-bearing cast for 4-6 weeks for avulsion and 6-8 weeks for body fractures. Any displacement should be treated with Open reduction internal fixation.
Navicular stress fractures are probably more common than initially thought. They most commonly occur in track athletes. Symptoms are usually vague and include midfoot pain with activity. Physical exam can reveal tenderness at the N spot, the dorsal midfoot between the anterior tibial tendon and the extensor hallicus longus tendon. CT scan is the preferred imagining, but MRI maybe helpful to rule out ligamentous injury or early stress reaction. Bone scans often show uptake in the navicular are not very useful. Most stress fractures can be managed conservatively and Torg, et al. showed similar healing rates between surgical and non-operative management. Non-operative management should be in a non-weight bearing cast for 6-8 weeks. The patient should be reexamined and if N spot tenderness is still present treated for another 2-3 weeks non-weight bearing. Follow up radiographs are generally not helpful. Return to sports usually takes 4-6 months. Weight-bearing treatment results in high failure rates and should be avoided.

References:
Burne SG et al. Tarsal navicular stress injury: long-term outcome and clinicoradiological correlation using both computed tomography and magnetic resonance imaging. Am J Sports Med. 2005;33:1875-81 [PMID:16157855

Eff, MP, et al. Fracture Management for Primary Care, 2nd edition. 2003.

Potter NJ et al. Navicular stress fractures: outcomes
of surgical and conservative management. Br
J Sports Med. 2006;40:692-5; discussion 695
[PMID:16611725]]

Torg JS, et al. Management of tarsal navicular stress fractures: conservative versus surgical treatment: a meta-analysis. Am J Sports Medicine. 2010 May; 38 (5): 1048-53

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