eMedicine Specialties > Sports Medicine > Foot and Ankle

Navicular Fracture: Differential Diagnoses & Workup

Author: Michael J Ameres, MD, Consulting Staff, Department of Emergency Medicine, Southampton Hospital
Coauthor(s): Greg Montalbano, MD, Assistant Clinical Professor, Department of Orthopaedics, New York University Medical School; Rafat Farouqui, MBBS, Consulting Staff, Department of Orthopedic Surgery, Brooklyn Hospital Center; Benson Yeh, MD, Assistant Program Director, Department of Emergency Medicine, Brooklyn Hospital Center; Clinical Instructor, Department of Medicine, Division of Emergency Medicine, Cornell University
Contributor Information and Disclosures

Updated: Feb 11, 2008

Differential Diagnoses

Ankle Fracture
Ankle Sprain
Athletic Foot Injuries
Contusions
Metatarsal Stress Fracture
Metatarsalgia

Other Problems to Be Considered

Accessory navicular: This condition manifests clinically as a painful bump of the medial navicular and is usually treated conservatively with nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, and/or orthotics. It may require excision for persistent pain.

Avascular necrosis of the navicular

Calcaneus bone injury

Köhler disease38,39,40 : Osteochondrosis of the navicular usually manifests in children younger than 6 years and is treated with short leg cast for up to 8 weeks.

Other midfoot fractures or dislocations

Planovalgus foot41

Workup

Imaging Studies

  • Radiograph
    • A plain radiograph of the foot rarely demonstrates the presence of a navicular stress fracture. For this reason, negative radiographic findings cannot be used to rule out the presence of a navicular fracture.
    • The tarsal navicular is frequently underpenetrated during routine standing anteroposterior (AP), lateral, and oblique views of foot; however, a coned-down AP radiograph that is centered on the tarsal navicular may help in visualization. The continuity of the cortical bone, especially on an AP radiograph, should be carefully examined because when a fracture is present, the lateral fragment may resemble a separate tarsal bone and can be easily overlooked. However, even with special techniques and a careful examination, a radiograph is not sufficient to rule out a stress fracture of the tarsal navicular.
  • Technetium (99m Tc) bone scanning
    • This study is useful for making the diagnosis of a navicular stress fracture.
    • Increased radionuclide uptake occurs at the navicular.
    • This modality is sensitive to, but not specific for, a fracture; therefore, a computed tomography (CT) scan is necessary for a definitive diagnosis.
  • CT scanning
    • These studies are useful for making and confirming the diagnosis of navicular stress fractures.  
    • In addition, a CT scan helps to more precisely define the location and extent of the fracture. Saxena et al proposed a classification system based on CT scan findings as follows42 :
      • Type 1 involves a dorsal cortical break.
      • Type 2 involves fracture propagation into the navicular body.
      • Type 3 consists of fracture propagation into another cortex.
      • Types 2 and 3 may benefit from early surgical intervention.
  • Magnetic resonance imaging (MRI)
    • MRI is the imaging modality of choice for diagnosing navicular stress fractures.
    • MRI is useful in grading the stress fracture, and thereby, this modality may help the clinician to adjust therapy based on the fracture severity.43,44
    • This study is relatively expensive.
  • Ultrasound20
    • Currently, ultrasound is not sensitive enough to be useful in the diagnosis of stress fractures. However, experience with this imaging technique for stress fractures is very limited.
    • The standard caveats for ultrasound apply. The technique is noninvasive but operator dependent. The role of ultrasound in diagnosing navicular stress fractures remains to be determined.

More on Navicular Fracture

Overview: Navicular Fracture
Differential Diagnoses & Workup: Navicular Fracture
Treatment & Medication: Navicular Fracture
Follow-up: Navicular Fracture
Multimedia: Navicular Fracture
References
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Further Reading

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Keywords

tarsal navicular fracture, midfoot fracture, mid-foot fracture, navicular stress fracture, navicular stress fractures, navicular cortical avulsion fracture, navicular tuberosity fracture, navicular body fracture, heel fracture, foot fracture, broken foot, navicular bone fracture, foot pain, N-spot, N spot

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Contributor Information and Disclosures

Author

Michael J Ameres, MD, Consulting Staff, Department of Emergency Medicine, Southampton Hospital
Michael J Ameres, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Greg Montalbano, MD, Assistant Clinical Professor, Department of Orthopaedics, New York University Medical School
Greg Montalbano, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Sierra Cascade Trauma Society
Disclosure: Nothing to disclose.

Rafat Farouqui, MBBS, Consulting Staff, Department of Orthopedic Surgery, Brooklyn Hospital Center
Disclosure: Nothing to disclose.

Benson Yeh, MD, Assistant Program Director, Department of Emergency Medicine, Brooklyn Hospital Center; Clinical Instructor, Department of Medicine, Division of Emergency Medicine, Cornell University
Benson Yeh, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Andrew L Sherman, MD, Assistant Professor, Departments of Neurological Surgery, Orthopedics, and Rehabilitation, University of Miami
Andrew L Sherman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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