Fracture of the navicular bone of the foot: Anatomy, Causes, Symptoms, First aid, Diagnosis, Treatment, Rehabilitation, Complications, Prevention

Foot injuries usually disable a person, cause severe pain and prevent normal movement. In addition, problems arise with the selection of shoes, because the foot swells greatly and it is not possible to put on the usual shoes.

The foot consists of many bones, cartilage and ligaments, muscles that provide a person with normal movement. The foot withstands enormous loads every day, while having a fairly small area. That is why treatment of fractured bones of the feet must be carried out promptly and correctly, otherwise the person’s gait changes, he suffers from chronic pain, and may even become disabled.

Anatomy

The foot consists of 26 bones that are connected to each other using joints. It is this structure that makes it flexible, which allows a person to maintain balance when moving. If one of the bones is damaged, the foot cannot function normally. Such violations also occur with a fracture of the scaphoid bone.

The navicular bone is located in the middle part of the foot and belongs to the tarsal bones. It connects to the talus, cuboid and sphenoid bones. This close arrangement most often results in multiple bone fractures; an isolated fracture of the scaphoid is rare.

Scaphoid fracture

Fractures of the navicular bone of the foot are a rare pathology in the general population, but are widely represented among athletes and people involved in sports involving running and jumping.

Fractures of the navicular bone of the foot are divided into two main groups: traumatic fractures and stress fractures. Traumatic fractures are in turn subdivided into avulsion fractures, tuberosity fractures and scaphoid fractures.

Avulsion fractures often result from sudden plantar flexion of the foot. In most cases, treatment is conservative, with the exception of an avulsion fracture of the navicular tuberosity with the tibialis posterior tendon, when surgery is required to prevent the development of flat feet.

Fractures of the bone body are often associated with high-energy trauma and are divided into 3 types based on their severity. Type 1 – fractures without displacement of fragments, type 2 – fractures with medial displacement of the forefoot, type 3 – comminuted impression fractures, with external displacement of the forefoot.

Stress fractures of the scaphoid were first described by Brehaulpt in 1855 in soldiers after a long forced march. As running became more popular, the incidence of this type of fracture increased in the general population.

-Dull, aching pain in the midfoot

-Edema

-Pain on palpation

-Frequently, full range of motion

In addition to the standard frontal and lateral projections, it is necessary to perform radiography at an angle of 45°. If radiography shows nothing but clinically there are signs of a fracture, a CT or MRI is recommended.

For avulsion fractures and most tuberosity fractures and type 1 shaft fractures, conservative treatment is indicated. A circular plaster cast is used up to the third of the shin, walking with crutches for 6-8 weeks from the moment of injury, followed by physical therapy.

In the case of acute traumatic fractures of types 2 and 3, as well as tuberosity fractures with significant displacement, surgical treatment is most often indicated - open reduction and osteosynthesis.

Depending on the morphology of the fracture, the operation may consist of a simple osteosynthesis with a single screw, or a complex reconstruction using bone grafts and bridge fixation with a plate or even arthrodesis.

Various osteosynthesis techniques are brilliantly presented on the website of the osteosynthesis association https://www2.aofoundation.org.

For stress fractures of the scaphoid, conservative treatment is almost always used as a first measure using the same method as for traumatic fractures, that is, immobilization in a circular plaster cast or rigid orthosis from the toes to the knee joint for a period of 6-8 weeks. However, in the group of professional athletes, it is advisable to consider the option of early surgical treatment in order to reduce rehabilitation time and speed up the return to training.

Stress fractures of the scaphoid are becoming increasingly common among physically active people. The diagnosis is often made untimely, since many traumatologists are not familiar with this pathology and there are certain difficulties in diagnosis. The athlete often complains of a dull pain that gradually increases over a long period of time and radiates to the distal parts of the foot, along the medial longitudinal arch. Radiographs often do not show any changes, and in this situation it is necessary to have a clinical sense in order to prescribe scintigraphy or CT/MRI.

The scaphoid bone is anatomically predisposed to stress fractures. It has a concave shape and is sandwiched between the head of the talus on one side and the three sphenoid bones on the other. During foot propulsion, the navicular bone experiences high compressive loads. In addition to this physiological impingement, the scaphoid bone is characterized by a rather poor blood supply, with a watershed zone just in its middle part.

The fracture itself is preceded by a long period of ischemia and increased stress, bone resorption, which can be detected by scintigraphy before the fracture line itself appears on CT or MRI.

A number of studies have identified several possible predisposing factors to fracture: cavovarus foot deformity, short first metatarsal, shoes with an excessively wide rear part, metatarsus adductus, limited movement of the subtalar joint, limited dorsiflexion of the foot. However, the main factor still remains excessive physical activity, which becomes a consequence of an incorrect training regimen, incorrect running technique, poor equipment, and exceeding the limit of the capabilities available to a given anatomical constitution.

The blurred clinical picture makes the diagnosis of scaphoid stress fractures difficult. Dull aching pain in the area of ​​the arch of the foot can be so weak that the athlete will continue to train through the pain, the full range of movements is maintained, the pain is provoked by standing on the toes, palpating the area of ​​the navicular bone. Plain radiographs reveal scaphoid stress fractures in only 30% of cases. Scintigraphy, on the contrary, is the most accurate method that allows you to detect changes in the bone before the actual fracture line occurs. However, all bone scan results must be additionally monitored using CT or MRI, since if a fracture is present, they do not allow assessment of its morphology.

When performing a CT scan, it is optimal to use a small step (1.5 mm) and make sections in the plane of the talonavicular joint. CT often reveals an incomplete fracture starting proximally along the dorsum and extending obliquely toward the distal plantar surface.

A large arrow indicates a fracture of the scaphoid, two small arrows indicate synostosis of the calcaneus and scaphoid.

Based on the CT image, patients can be divided into 3 groups: type 1 - isolated fractures of the dorsal cortical plate, type 2 - fracture of the dorsal cortex and bone body, type 3 - complete fracture of the scaphoid. The severity of the course and the time of fusion increase respectively from type 1 to type 3.

MRI is the second most sensitive study and is becoming an alternative to scintigraphy. Bone swelling on T-2 weighted images reveals bone changes that precede fracture. MRI is not advisable to perform if scintigraphy and CT have already been performed.

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In 80% of cases of non-displaced scaphoid fractures, 6 weeks in a circular plaster cast without putting any weight on the injured limb is sufficient for recovery. After immobilization, physical rehabilitation begins, the load gradually increases under the supervision of a specialist, and when pain returns, the load is reduced. If conservative treatment is ineffective, surgical treatment is recommended. Most often, surgical treatment is reduced to compression osteosynthesis with one or two screws, sometimes with the use of osteoconductive materials.

The average time to complete rehabilitation is from 3 to 6 months, depending on the morphology of the fracture.

You may also be interested in the following articles:

- ankle fracture

- fracture of the 5th metatarsal bone

- Lisfranc joint

- Achilles tendon rupture

- flat feet in adults

Causes

The scaphoid bone can be injured due to direct and indirect impacts. In the first case, there is a strong blow to the foot area, for example, if an object falls from a height directly onto the foot. In the second case, with an awkward movement, tucking the foot, the muscles become very tense, while tight shoes compress the foot, as a result of which the bones may not withstand the load and break.

The following groups of people are more susceptible to such injuries:

• Persons who wear tight and uncomfortable shoes, especially high heels;
• Athletes, in particular those with heavy loads on their legs;
• Patients are elderly, as bones become more fragile over the years.

A fracture of the scaphoid bone can occur in an accident if there is a blow to the foot area or a car runs over it. The weight of the car causes multiple fractures, including the scaphoid bone. This injury is often accompanied by displacement of fragments.

Stress fractures of the scaphoid are also common. They usually occur in athletes whose legs undergo enormous loads. Most often this occurs in dancers, football players, gymnasts, and figure skaters. From daily training, the bones of the foot can change their structure and cannot withstand loads. There may also be a re-fracture if the patient began to train without completing treatment. The fracture line passes through the fragile callus.

Reasons for appearance

Ostechondropathy is a consequence of one or more of the pathologies described below.

• Genetic predisposition - the disease is more often diagnosed in patients whose parents are susceptible to the same pathology;
• Circulatory disorders - its nature can be congenital, traumatic, or be a consequence of metabolic disorders;
• Metabolic disorders, including carbohydrate, fat, purine;
• Irrational or malnutrition, causing a deficiency of vitamins, micro-, macroelements (calcium, phosphorus, magnesium, etc.);
• Long-term eating disorders: bulimia, anorexia;
• Alimentary (nutritional) or hormonal obesity, overdeveloped muscle mass;
• Bacterial, viral infections;
• Traumatic injuries;
• Endocrine pathologies;
• Neurotrophic disorders;
• Long-term use of corticosteroid hormones.

The cause of the most commonly diagnosed osteochondropathy of the calcaneus is chronic microtrauma. They appear, for example, as a result of prolonged exposure to a forced unnatural position or regular high loads placed on the same joint. Osteochondropathy of the calcaneus is diagnosed in professional athletes: gymnasts, acrobats, figure skaters, fencers.

Symptoms

Any fracture of the scaphoid is accompanied by characteristic symptoms, which are more pronounced when the ligaments are torn and bone fragments are displaced, since not only the bone is injured, but also the tissues surrounding it.

General symptoms:

• An aching pain appears, which becomes sharp if a person tries to step on the sore leg, and the pain also intensifies if you press your fingers on the bone.
• The tissues around the site of injury swell, often the swelling can be local and located only above the navicular bone, in other cases the entire foot swells, up to the ankle joint;
• When a fracture occurs, the vessels are usually damaged and a hematoma occurs;
• If bone fragments are displaced, a visible bump appears on the back of the foot;
• The patient assumes a forced posture and gait, while relying only on the heel of the sore leg;
• When trying to turn the foot inward or outward, lower it down or lift it up, the patient feels severe pain.

It is important to note that when a foot fracture occurs, visible symptoms do not always appear immediately. Often the patient may feel only pain when moving for several hours, or even throughout the entire day. Many people even manage to work with such a problem, but this cannot be done. If you don't see a doctor, the bone will heal incorrectly and your foot will function poorly, resulting in lameness that will last a lifetime.

Closed foot fracture

A closed fracture of the foot can occur in the following areas:

• Sometimes the talus bone is affected, which is a fairly serious injury. This is due to some of its features: body pressure is transferred through it to the feet, it is responsible for the formation of their arches, and is also the only bone that does not have a ligament with any muscle. Recovery takes a long period of time, since the bone does not have a normal blood supply. Nutrients reach it only through small vessels surrounding the tissues. It accounts for up to 3% of all foot injuries. But in isolation it is very rarely damaged; it is more often combined with ankle fractures, dislocations of joints, etc. In order for the integrity of the talus to be damaged, an indirect impact is necessary: ​​a jump or fall from a height, an eversion of the leg. More often the neck of the bone suffers, which is then complicated by backward dislocation of the bone block.
• Sometimes the calcaneus is damaged; it suffers somewhat more often than the talus. The method of traumatizing it is monotonous - it is landing from a height on the feet, when the main emphasis is on the heel. In this case, the talus bone is wedged into it, which is why a split occurs. Most often, both legs are injured. The stronger the blow, the more difficult the fracture will be. It can be: simple, fragmented, comminuted, intra-articular and extra-articular, with or without displacement.
• When the bones of the metatarsus break, it is most often caused by an object falling on them from a height, squeezing it, or running over it, for example, a car wheel. One or several bones that are part of it may be injured, with damage to the head, neck or body. It is the metatarsal bones that are most often broken.
• When the phalanges of the fingers are injured, it is due to a direct blow. Often with such fractures, a person may continue to step on the limb and does not seek help from a doctor. Meanwhile, malunion often results in serious consequences, for example, post-traumatic arthrosis develops. If the fracture occurs inside the finger joint, then this leads to stiffness and walking becomes difficult for the victim, then people are sent to the emergency department faster.

First aid

For any injury, the victim must be given first aid, including fractures of the tarsal bones. If you do not immobilize the leg and take the patient to the hospital without fixing the foot, then the bone fragments may move along the way, then the doctor will not limit himself to just a cast, he will have to perform an operation.

When the scaphoid bone is fractured, the patient experiences severe pain. If the leg shakes freely during transportation, this will be an additional burden for the victim and will lead to increased pain.

To prevent complications and reduce pain, transport immobilization is performed. If an ambulance was called for the patient, he should be placed on his back on a flat surface and asked not to move his leg. Immobilization will be carried out by specialists in accordance with all the rules.

If the decision was made to take the victim to the hospital on his own, he is given pain medication and immobilized with a splint and bandage. As a tire, you can use boards, plastic plates, metal rods or thick cardboard. The splint is fixed with a clean cloth or bandage. If the fracture is open, apply a protective bandage to the wound to reduce the risk of infection in the wound.

It is very important to take the victim to the hospital as quickly as possible, then there is a greater chance that the fracture will heal correctly. Delay worsens the prognosis and increases the risk of complications.

Treatment of a foot fracture

Treatment of a foot fracture depends entirely on the location, extent and nature of the injury:

• If the heel bone is damaged without displacement, the doctor will apply a plaster cast. It starts from the fingers and ends at the knee area. Particular attention should be paid to the longitudinal arch of the foot. On average, you will have to wear such a cast for a couple of months. If there is displacement, then a one-stage reposition is first applied, after which a plaster cast will be applied. The osteosynthesis method is often used, which is recommended 14 days after injury. The Ilizarov apparatus is used if the fracture is comminuted.
• When the tarsal bones are injured, both the reposition method and transosseous osteosynthesis are used, rarely, but the skeletal traction method is used. The cast will be applied for an average of 3 months.
• When the fracture affects the phalanges of the fingers or metatarsal bones, a splint is required. Its length extends to the knee joint.
• For multiple fractures, treatment is complex and lengthy, and sometimes surgery may be required.

On topic: 12 folk methods for home treatment

Diagnostics

First, the patient is examined and interviewed. Usually, the doctor identifies fractures of the tarsal bones immediately by characteristic signs. In addition, the doctor asks how the injury occurred, whether there was a strong blow, what kind of lifestyle the patient leads, and whether there have been fractures of the foot bones in the past.

It is only possible to accurately determine the location of the scaphoid fracture, the presence of fragments and damage to adjacent bones using radiography. Therefore, the patient is sent for an x-ray before starting treatment. The image immediately shows the deformation of the bone and a violation of its integrity.

How long does it take for a foot fracture to heal?

The time it takes for injured foot bones to recover varies widely.

It may increase or decrease depending on the nature of the injury and the area of ​​damage:

• An isolated fracture of the posterior process is restored in one month.
• Fracture of the body and neck of the talus up to 3 months.
• The metatarsal bones fuse in 1.5 months.
• The phalanges of the fingers can heal in 6 weeks or earlier.
• The tarsal bones can recover in either a month or six months if a pronounced displacement has been observed.

If qualified assistance was provided, and during the recovery stage the patient followed all the doctor’s instructions, the foot fracture will heal faster. On average, this time is 2 – 3 months.

Find out more: 4 phases of fracture healing

Treatment

For a fracture without displacement of bone fragments, conservative treatment is prescribed. The doctor applies a plaster cast, in which modeling the arch of the foot plays an important role. With a fracture of the scaphoid there is always a distortion of the transverse arch, and if the plaster is applied incorrectly, the patient will suffer from flat feet in the future.

If a displaced fracture of the scaphoid bone occurs, the bone is replaced in place using skeletal traction. Depending on the number of bone fragments, doctors can perform traction manually, or install a special Cherkes-Zadeh apparatus. In the first case, one doctor holds the foot, and the other pulls the toes, forcing the bone fragments into place.

In more severe cases, surgery may be performed even with complete removal of bone fragments. The empty space in the bone is filled with a special bone graft. For these purposes, artificial materials are most often used, sometimes part of the tibia.

Nowadays, it is not recommended to completely remove the navicular bone, as it is known that this leads to severe deformation of the foot and impaired motor activity. The patient's gait changes forever, he limps and cannot wear his usual shoes. Therefore, doctors are trying their best to restore this small bone in order to provide the patient with a normal life after treatment. Connection of fragments is possible using osteosynthesis.

Treatment of non-united fractures and false joints

A false joint (non-union fracture) is a medical situation when the attending physician is confident that the fracture no longer has a chance of healing without surgical intervention. The presence of a pseudarthrosis leads to permanent loss of limb function and loss of the usual quality of life.

It happens that “missed” and not diagnosed fractures heal in time. And, conversely, perfectly operated fractures do not heal at all. In both cases, specialists from the Ilyinskaya Hospital will help you get out of a difficult situation. For simplicity of presentation, we will combine non-union fractures and pseudarthrosis into one group. Although, from a medical point of view, this is not exactly the same thing.

• What is a false joint

This is a situation where a bone fracture is present, but the healing process has stopped. In this case, surgery is required. As a rule, a fracture is considered non-union 9 months after its occurrence, provided that there is no radiographic progress in healing during the last 3 months. Some fractures, for example, the femoral neck, humerus, scaphoid bone of the hand or talus of the foot and some others can be defined as “non-union” already 3 months after the injury.

• Difference between delayed union and non-union fracture (false joint)

Surgeons speak of delayed fusion when the usual time frame for fusion (consolidation) for a given particular fracture is exceeded, however, the process of fusion, albeit slowly, continues. A non-united fracture is a situation where healing is no longer possible without surgery.

• Types of false joints

All pseudarthrosis and non-union fractures can be divided into two large groups. The first is biologically active, with good blood supply. To treat them, one or another surgical method is used to increase the stability of fracture fixation. The second is biologically inactive, with poor blood supply and a tendency to atrophy. In addition to increasing the stability of fracture fixation, in this case it is necessary to improve the local blood supply. For this, different methods are used: from Ilizarov technology to bone transplantation on feeding vessels using microsurgical techniques. In some cases, artificial bone substitutes can be successfully used.

• Surgical treatment of non-union fractures and pseudarthrosis

Treatment of nonunion fractures and pseudarthrosis has three components: control of infection (if present), improvement of blood supply, and surgical stabilization of the bone with a suitable implant in the correct position. Each of the three tasks is an entire direction in modern medicine. Choosing the optimal treatment path for each individual patient is a difficult task. The surgeon is required to have in-depth knowledge and experience in the treatment of these particular pathological conditions and an expert level of proficiency in surgical technique. This is reconstructive surgery of the highest level, which is meticulously mastered by specialists from the Ilyinskaya Hospital. It is important to understand that age is not an obstacle to such an operation. Anesthesiologists at the Ilyinskaya Hospital will select the safest type of anesthesia, and in the postoperative period the patient will be provided with the best care and complete pain relief.

• Pain Management Service

The Ilyinskaya Hospital has implemented the concept of a “hospital without pain.” Our specialists have a full range of analgesics, including powerful opioid drugs. For the most persistent pain syndromes, therapeutic blockades, nerve stimulation with a high-frequency electric field, implantation of electrodes to stimulate the spinal cord and individual nerves are used, and special systems are used that inject morphine directly into the cerebrospinal fluid.

• Rehabilitation

Postoperative management of patients operated on for a pseudarthrosis is entirely based on the characteristics of the operation performed. For each patient, the rehabilitation specialists at the Ilyinskaya Hospital draw up an individual rehabilitation program that takes into account his capabilities and individual characteristics. Rehabilitation specialists at the Ilyinskaya Hospital, in collaboration with the operating surgeon and general practitioners, will make the recovery process as fast and efficient as possible.

Rehabilitation

The rehabilitation period plays an important role in the treatment of a scaphoid fracture. The injured area gradually recovers and heals under a plaster cast. After its removal, muscle weakness is observed, caused by atrophy from prolonged inactivity. Movement in the ankle joint is limited due to the fact that the leg has been immobile for a long time.

Therefore, it is very important to prepare the foot before returning to normal life. The following procedures will help improve blood circulation, strengthen muscles, and restore range of motion in joints:

• Physiotherapy. The load increases gradually;
• Swimming in the pool;
• Therapeutic massage will help improve blood circulation and remove congestion in the tissues that have formed during long-term wearing of the cast;
• Wearing orthopedic shoes and insoles. This is necessary to correct the arch of the foot, otherwise flat feet will occur. Wear orthopedic devices for at least a year after the fracture;
• During the rehabilitation period, you need to take extra care of your feet; at the end of the working day, massage them at home and keep your feet in warm baths; this will help relieve fatigue after a hard day, improve blood circulation and reduce swelling.

Folk remedies

Traditional medicine for a fracture of the scaphoid is used only in complex treatment, mainly in the recovery period.

During the rehabilitation period, the patient is recommended to regularly take foot baths. It can be ordinary water at a temperature like fresh milk. Water relaxes muscles; movements in water are much easier than under normal conditions.

Traditional medicine offers the following bath recipes:

• Baths with chamomile or chamomile have an anti-inflammatory effect. To prepare them, 3-4 tablespoons of herbs are brewed in 500 ml of boiling water and left to brew under the lid. The cooled liquid should be filtered and poured into a bath of warm water, and place your feet in it for 15 minutes.
• Baths with sea salt also have a positive effect on the feet, and are very simple to prepare. It is enough to dissolve half a glass of natural sea salt in warm water and soak your feet in the solution for 15-20 minutes.

It is very important that there are no wounds or irritations on the skin during the treatment period. If the integrity of the skin is compromised, local products cannot be used. For the best effect, after the bath you need to perform self-massage with a moisturizing or medicinal cream, if prescribed by a doctor. The cream is applied to the skin and gently rubbed over the entire foot.

Swelling after a foot fracture, what to do

After a foot fracture, swelling almost always occurs. This is normal and typical for this type of injury. If the swelling persists for a long time and does not subside, then this causes a certain discomfort to the person.

In order to understand how to deal with edema, you should understand the reasons for its appearance:

• If swelling occurs immediately after injury, it is due to the accumulation of fluid in the soft tissues surrounding the bone due to their deformation. Normally, it should subside within a couple of days and go away completely after removing the immobilizing bandage.
• If swelling remains after the cast is removed, it may be the result of lymphatic stagnation. It is produced in large quantities, and its outflow is difficult. This can lead to a number of complications, for example, the formation of ulcers, cysts, fibrosis. Therefore, it is necessary to deal with edema in a timely manner.

In order to get rid of stagnation, it is worth making some efforts. In particular, they will help to cope with them:

• Performing a foot massage. If it is not possible to visit a specialized office, then it should be done at home. To do this, you should take fir oil, which will be an excellent assistant in the fight against swelling. Movements should be gentle, starting with kneading and stroking, then you can move on to patting and rubbing. It is important that the person does not experience discomfort.
• You cannot do without a course of exercise therapy designed specifically to relieve swelling from the foot. It consists in increasing its mobility due to the work of the ankle and knee joints. Be sure to use your toes.
• You can visit the physiotherapy room, where a number of procedures recommended by the doctor will be performed.
• You should definitely review your diet and remove excess salt from it. After all, it is what promotes fluid retention in tissues.
• Sometimes doctors advise using ointments that improve blood circulation in the foot.

In addition to the basic recommendations, you need to increase physical activity: walk long distances, visit the pool and gym. Not a single edema can resist such an integrated approach and the swelling on the foot will disperse without leaving a trace.

Complications

If you consult a doctor in a timely manner, the prognosis is most often favorable, especially in young people. If the fracture is significantly displaced or occurs in an elderly patient, or the victim goes to the hospital untimely, the fracture may be complicated:

• After the bones heal, chronic foot pain and lameness appear;
• Flattening of the arches of the feet;
• Valgus deformity;
• Shortening of the foot;
• Impaired motor activity, the foot cannot be turned to the sides, contracture of the ankle joint.

Main causes of injury.

There are general and local reasons due to which the process of bone tissue restoration slows down. These include:

• Serious diseases (diabetes mellitus, osteoporosis)
• Bad habits (smoking, alcohol)
• Exhaustion of the body
• Old age (over 60 years old)
• Numerous fractures
• Dysmenorrhea in women
• Penetration of infection or foreign bodies into the wound
• Serious soft tissue damage
• Circulatory disorders

Prevention

Fracture prevention is difficult to carry out, since injuries occur accidentally. Of course, you should avoid traumatic situations, cross the road correctly, wear comfortable shoes and not overexert your feet. It is also recommended to eat right and lead an active lifestyle to strengthen the body.

To prevent complications, you need to consult a doctor immediately after an injury and undergo adequate treatment. A responsible attitude towards your health will help you quickly get rid of the problem and reduce the risk of complications.