01Approach to the Critical Patient/attcp33

Immediate priorities

›Limb-threatening emergencies

›Open fracture

›Wound contamination and tissue exposure

›Operative washout within 6 hours

›Neurovascular compromise

›Absent dorsalis pedis or posterior tibial pulse

›Capillary refill >2 seconds

›Compartment syndrome

›Pain out of proportion to injury

›Pain with passive toe extension

›Tense compartments on palpation

›If compartment syndrome suspected, emergent orthopedic consultation

Key decision points

›Fracture type branching

›Acute traumatic fracture vs stress fracture distinction

›Acute: sudden mechanism, focal swelling, ecchymosis

›Stress: insidious onset, activity-related dorsomedial pain over weeks to months

›Displacement assessment on plain radiograph

›Displacement >1 mm or shortening >2 mm requires surgical referral

›Avulsion fragment >20% of talonavicular joint surface requires orthopedic review

›Concomitant Lisfranc injury screen

›Plantar ecchymosis and midfoot swelling

›Tarsometatarsal joint tenderness

Monitoring and stabilization

›Acute stabilization bundle

›Posterior splint or boot immobilization

›Non-weight-bearing positioning

02History/hx66

Mechanism and onset

›Acute traumatic fracture mechanisms

›Axial load through foot

›Landing from height

›Stepping off a curb

›Twisting or inversion injury

›Sudden direction change

›Sports-related pivot

›Direct crush injury

›Object falling on foot

›Motor vehicle injury

›Stress fracture presentation

›Insidious onset dorsomedial midfoot pain

›Worsens with activity, improves with rest

›Progressive over weeks to months

›Activity association

›Sprinting and jumping sports

›Explosive cutting movements

›Mean symptom duration before diagnosis approximately 10 months

›Frequently missed or diagnosed late

›High index of suspicion required

Pain characterization

›Location and quality

›Dorsal proximal navicular tenderness

›N spot: point tenderness over dorsal proximal navicular for stress fractures

›Highly sensitive finding

›Dorsomedial midfoot for acute fractures

›Radiation down medial arch

03Physical Exam/exam51

Vitals and general

›Initial assessment

›Vital signs for polytrauma exclusion

›Hemodynamic stability

›Tachycardia suggesting significant blood loss in high-energy trauma

›General appearance

›Weight-bearing ability

›Gait assessment if ambulatory

›Comparison to contralateral foot

›Asymmetry in swelling, deformity, or arch height

Foot and ankle exam

›Inspection

›Midfoot swelling and ecchymosis

›Dorsal swelling over navicular

›Plantar ecchymosis raising Lisfranc concern

›Medial longitudinal arch assessment

›Flattening indicating navicular body fracture with arch loss

›Deformity or shortening

›Palpation

›N spot tenderness

›Point tenderness dorsal proximal navicular

›Hallmark finding for stress fractures

›Systematic midfoot palpation

›Cuneiforms, cuboid, metatarsal bases

›Tarsometatarsal joint line for Lisfranc

›Posterior tibial tendon

›Medial ankle to navicular tuberosity

›Tenderness or avulsion concern

04Differential Diagnosis/ddx49

Life threats and structural emergencies

›High-priority diagnoses

›Lisfranc injury

›ICD-10 S93.3

›Midfoot swelling, plantar ecchymosis, tarsometatarsal tenderness

›Can coexist with navicular fracture

›Compartment syndrome foot

›ICD-10 M79.7

›Pain out of proportion, tense compartments

›Surgical emergency

›Fracture-dislocation

›High-energy mechanism

›Gross deformity and neurovascular compromise

Adjacent tarsal injuries

›Bony injuries in the region

›Cuboid fracture

›ICD-10 S92.21

›Lateral midfoot tenderness

›Nut-cracker mechanism

›Cuneiform fracture

›ICD-10 S92.22

›Overlapping presentation with navicular injury

›Calcaneal fracture

›ICD-10 S92.0

›Heel pain, heel widening, Bohler angle reduction

Soft tissue and overuse diagnoses

›Common mimics

›Midfoot sprain

05Laboratory Tests/lt34

Stress fracture metabolic workup

›Bone health assessment labs

›25-hydroxyvitamin D level

›Target level above 50 nmol/l

›Deficiency common in athletes with stress fractures

›Calcium and phosphorus

›Baseline metabolic assessment

›Hypocalcemia contributing to bone fragility

›Alkaline phosphatase

›Marker of bone turnover

›Thyroid stimulating hormone

›If endocrine dysfunction suspected

›Hypothyroidism and hyperthyroidism affect bone density

›Female athlete triad workup

›LH, FSH, estradiol

›Menstrual irregularity assessment

›Amenorrhea and oligomenorrhea as RED-S markers

›Bone mineral density by DEXA

›Indicated for recurrent stress fractures or RED-S

›Z-score below negative 2 indicates low bone density for age

Acute fracture labs

›Not routinely required for isolated acute traumatic fractures

›CBC, CMP for polytrauma or planned surgical intervention

›Pre-operative baseline

›Type and screen if operative management anticipated

›Significant blood loss unlikely with isolated injury

›Glucose

›Diabetes impairing healing consideration

06Diagnostic Tests/dt83

Scoring Systems

›Ottawa Foot Rules

›Indications for foot radiography after acute injury

›Midfoot tenderness at the navicular warrants imaging

›Midfoot tenderness at the base of the fifth metatarsal

›Inability to bear weight for four steps immediately after injury and in the emergency department

›Navicular tenderness is a specific Ottawa trigger point

›High sensitivity for navicular fracture

›Reduces unnecessary radiography

›Saxena classification for navicular stress fractures

›Based on CT findings

›Type I: dorsal cortex fracture only

›Type II: fracture extends into navicular body

›Type III: complete fracture through both cortices into plantar cortex

›Type III associated with highest complication risk

›Highest nonunion rate

›Surgical management most often indicated

›Bone stress injury prediction tools

›Clinical prediction score

›Score of 3 or higher raises suspicion for bone stress injury

›Integrates activity level, pain with activity, localized tenderness

›Clinical trajectory assessment

›No single score replaces clinical judgment

›ACEP Level C recommendation for adjunct use

MRI

›MRI indications for navicular fracture

›Stress fracture evaluation

›Most sensitive modality for early stress reactions and bone marrow edema

›Detects pre-fracture bone stress before cortical breach

›Evaluates associated soft tissue and ligamentous injury

›Negative radiograph with high clinical suspicion

›Preferred over bone scan due to superior specificity

›Avoids radiation exposure

›Soft tissue assessment

›Posterior tibial tendon integrity

›Talonavicular and naviculocuneiform ligaments

›MRI protocol and interpretation

›T2 and STIR sequences

›Bone marrow edema appearing as high signal

›Extent of edema correlates with severity

›Cortical disruption on T1

›Low signal cortical fracture line

›Avascular necrosis assessment with gadolinium

›Limitations

›Cost and availability

›Implant contraindications

CT

›CT indications for navicular fracture

›Anatomic detail for acute fractures

›Fracture line characterization and displacement measurement

›Comminution and intra-articular extension

›Saxena classification of stress fractures

›Essential for Type I vs Type II vs Type III distinction

›Guides conservative vs surgical decision

›Surgical planning

›Displacement greater than 1 mm

›Shortening greater than 2 mm

›CT technique and findings

›Thin-slice axial with sagittal and coronal reconstructions

›1 mm slice thickness preferred

›Acute fracture findings

›Fracture line, fragment position, articular surface involvement

›Air fluid level or cavitation in high-energy injury

›Stress fracture findings

›Dorsal cortical fracture line

›Sclerosis and cortical thickening with chronic stress

›Healing assessment

›CT confirms bridging callus before return to sport

›Mean return to sport 4 to 5 months

Ultrasound

›Ultrasound role in navicular fracture

›Limited for navicular fracture diagnosis directly

›Bone cortex visible superficially

›Cortical disruption may be seen in acute fractures

›Soft tissue assessment

›Posterior tibial tendon evaluation

›Fluid in tendon sheath suggesting tendinopathy

›Dynamic assessment of adjacent structures

›Talonavicular joint effusion

›Ligament assessment with experienced operator

›POCUS adjunct role

›Neurovascular assessment

›Doppler for dorsalis pedis and posterior tibial flow

›Adjunct to clinical pulse assessment

›Hematoma assessment

›Soft tissue swelling characterization

›Not primary diagnostic tool for fracture

07Disposition/dispo45

Emergency department disposition

›Discharge with orthopaedic follow-up

›Most navicular fractures can be discharged from ED

›Posterior splint or boot immobilization

›Non-weight-bearing crutches

›Non-displaced dorsal avulsion fracture

›Short leg walking boot 4 to 6 weeks

›Weight-bearing as tolerated

›Non-displaced tuberosity avulsion fracture

›Short leg walking boot 4 to 6 weeks

›Weight-bearing as tolerated

›Non-displaced body fracture

›Short leg cast or boot 6 to 8 weeks

›Consider initial 4 to 6 weeks non-weight-bearing if significant pain

›Stress fracture suspected

›Strict non-weight-bearing cast

›Sports medicine or orthopaedic referral

Orthopedic referral indications

›Urgent orthopedic consultation

›Displaced body fracture

›Displacement greater than 1 mm

›Shortening greater than 2 mm

›Comminution

›Avulsion fragment criteria

›Dorsal avulsion involving more than 20% of talonavicular joint

›Tuberosity avulsion with more than 1 cm displacement

›Suspected Lisfranc injury

›Concurrent midfoot injury requiring stabilization

08Treatment/t75

Acute fracture management

›Nondisplaced dorsal avulsion fracture

›Immobilization

›Short leg walking boot or cast

›Duration 4 to 6 weeks

›Weight-bearing

›Weight-bearing as tolerated immediately

›Transition to hard-soled shoe at 4 weeks if healing evident

›Radiographic confirmation of healing

›Nondisplaced tuberosity avulsion fracture

›Immobilization

›Short leg walking boot

›Duration 4 to 6 weeks

›Weight-bearing as tolerated

›Supportive footwear after immobilization

›Nondisplaced body fracture

›Immobilization

›Short leg walking cast or boot

›Duration 6 to 8 weeks

›Non-weight-bearing consideration

›Initial 4 to 6 weeks NWB if significant swelling or pain

›Transition to weight-bearing when tolerated

Surgical management

›Displaced body fracture surgical indications

›Open reduction internal fixation

›Displacement greater than 1 mm or shortening greater than 2 mm

›Comminuted fractures

›Fracture-dislocation

›Postoperative protocol

›Non-weight-bearing 4 to 6 weeks postoperatively

›Gradual weight-bearing under orthopaedic guidance

›Stress fracture surgical management

›Indications for ORIF

›Displaced fractures

›Type III Saxena classification

›Nonunion or delayed union

›Elite athletes with Type II or III fractures

›Outcomes

›Operative management 96.3% success rate by meta-analysis

›Refracture rate 1.3% operative vs 23.5% conservative

›2025 international consensus recommends 4 to 6 weeks NWB postoperatively

›Return to full sport within 4 to 6 months

Conservative stress fracture management

›Strict non-weight-bearing immobilization

›Cast immobilization

›Short leg non-weight-bearing cast

›Minimum 6 weeks duration

›Outcome data

›NWB conservative treatment 96% successful outcome

›Weight-bearing conservative treatment only 44% success rate

›Weight-bearing conservative treatment has 56% failure rate

›Followed by 6-week graduated rehabilitation program

›Progressive weight-bearing

›Sport-specific conditioning

Analgesia

›Pain management principles

›Acetaminophen preferred analgesic

›1000 mg PO every 6 hours for adults

›First-line during stress fracture healing

›NSAIDs for acute traumatic fractures only

›Short course with caution

›Theoretical impairment of bone healing with prolonged use

›Avoid during stress fracture healing phase

›Ice and elevation for acute swelling

›20 minutes on, 20 minutes off

›Limb elevation above heart level

›Opioid avoidance when possible

›Short-course consideration for severe acute pain only

Metabolic optimization

›Bone healing support

›Calcium supplementation

›Target 1000 to 1200 mg per day from diet and supplement

›Calcium carbonate or calcium citrate

›Vitamin D supplementation

›25-hydroxyvitamin D target above 50 nmol/l

›Ergocalciferol or cholecalciferol 1000 to 2000 IU daily if deficient

›Protein intake optimization

›Adequate protein to support bone healing

›Smoking cessation counseling

›Smoking impairs fracture healing

09Special Populations/sp58

Pregnancy

›Pregnancy-specific considerations

›Imaging approach

›Plain radiograph with fetal shielding when clinically indicated

›Ottawa Foot Rules apply regardless of pregnancy

›MRI preferred over CT for stress fracture evaluation

›Avoid CT when MRI available to reduce fetal radiation exposure

›Analgesia

›Acetaminophen preferred analgesic in pregnancy

›NSAIDs avoided in third trimester

›Opioids with caution and only when necessary

›Immobilization

›Boot and crutches preferred when feasible

›Non-weight-bearing compliance may be challenging with advanced pregnancy

›Stress fracture risk factors in pregnancy

›Increased body weight and gait changes

›Calcium demands of fetal development

›Vitamin D requirements increased in pregnancy

Geriatric

›Older adult considerations

›Mechanism differences

›Lower-energy falls predominant mechanism

›Osteoporosis underlying risk

›Polymedication contributing to falls

›Imaging

›Plain radiograph usually sufficient for acute fracture

›MRI for occult fracture in osteoporotic bone

›Bone density assessment if not previously established

10Background/b75

Epidemiology

›Incidence and burden

›Navicular fractures approximately 35% of all tarsal fractures

›Avulsion fractures most common type approximately 50% of navicular fractures

›Body fractures approximately 20% of navicular fractures

›Stress fractures disproportionately affect athletes

›Stress fracture demographics

›Sports involving explosive movements highest risk

›Track and field, basketball, gymnastics, dance, soccer

›Female sex: 65% of adolescent navicular stress fractures occur in females

›Diagnostic delay

›Mean symptom duration before stress fracture diagnosis approximately 10 months

›Plain radiograph high false-negative rate for stress fractures

›High clinical suspicion essential

›Complications and natural history

›Avascular necrosis risk

›Central one-third of navicular has avascular watershed zone

›Predisposes to nonunion and osteonecrosis

›Refracture rate

›Conservative management refracture rate up to 23.5%

›Operative management refracture rate 1.3%

›Navicular stress fractures longest return-to-sport timeline among bone stress injuries

›Mean 127 days return to sport

Pathophysiology

›Anatomic basis of vulnerability

›Tarsal navicular as keystone of medial longitudinal arch

›Critical role in hindfoot motion and gait

›High mechanical stress with walking and running

›Avascular watershed zone

›Central one-third supplied by end-arteries

›Tenuous blood supply predisposing to nonunion and osteonecrosis

›Biomechanical predisposition

›Pes cavus and short first metatarsal increase stress

›High arch concentrates load on navicular

›Fracture mechanisms

›Acute traumatic fractures

›Dorsal avulsion: forced plantar flexion avulsing dorsal capsule

›Tuberosity avulsion: eversion force through posterior tibial tendon

›Body fracture: axial load and compressive force from talus and cuneiforms

›Stress fractures

›Repetitive cyclical loading exceeding bone remodeling capacity

›Cumulative microdamage progresses to cortical crack

›Metabolic factors amplify risk

›Healing biology

›Avascular central zone limits healing capacity

›Prolonged immobilization required

›Non-weight-bearing essential for successful outcome

›Bone remodeling timeline

›Cortical bridging typically 6 to 12 weeks

›Return to full sport 4 to 6 months post-treatment

Therapeutic Considerations

›Conservative vs operative evidence

›Stress fracture treatment evidence

›NWB conservative management 96% success rate

›Weight-bearing conservative management only 44% success rate

›Operative management 96.3% success rate with significantly lower refracture

›Meta-analysis by Torg et al 2010 supporting NWB conservative for nondisplaced

›2025 international consensus recommendations

›Operative management for displaced, Type III, and elite athletes with Type II

›4 to 6 weeks NWB postoperatively

›Return to full sport within 4 to 6 months

›Modica et al 2026 review supporting current management standards

›NSAID use in fracture healing

›Theoretical concern for delayed bone healing

›Prostaglandin inhibition reducing osteoblast activity

›Short-course acceptable for acute traumatic fractures

›Avoid during stress fracture healing phase

›Acetaminophen preferred analgesic during healing

›Prevention and recurrence reduction

›Training load modification

›Gradual progression principles

›Cross-training during recovery

›Nutritional optimization

›Female athlete triad and RED-S treatment

›Calcium and vitamin D adequacy

›Return-to-sport protocol

›CT confirmation of healing before return

›Progressive sport-specific loading

11Patient Discharge Instructions/pdi37

copy discharge instructions

›Navicular fracture home care

›Boot or splint must remain on at all times except bathing

›Do not remove for walking

›Protect with waterproof cover during bathing if removable boot

›Non-weight-bearing instructions

›Use crutches for all walking if instructed not to bear weight

›Do not put any weight on the injured foot until told by your doctor

›Weight-bearing as tolerated only if your doctor specifically approved

›Elevate the foot above heart level as much as possible

›Especially during the first 48 to 72 hours

›Reduces swelling and pain

›Ice application for swelling

›20 minutes on, 20 minutes off

›Protect skin with cloth between ice and skin

›Medications

›Acetaminophen 1000 mg every 6 hours as needed for pain

›Do not exceed 4000 mg per day

›Preferred pain reliever during bone healing

›Avoid anti-inflammatory medications during healing unless specifically advised by your doctor

›Ibuprofen and naproxen may impair bone healing

›Calcium and vitamin D supplements if prescribed

›Take daily to support bone healing

›Return to Emergency Department immediately for

›Increasing pain despite rest and elevation

›Numbness, tingling, or color change in toes or foot

›Inability to move toes

›Worsening swelling not improved by elevation

12References/r27

Guidelines and key sources

›Primary guidelines

›Silver S, Williams E, Plunkett ML: Common Foot Fractures. American Family Physician 2024

›Acute traumatic navicular fracture classification and management

›Ramadorai MU, Beuchel MW, Sangeorzan BJ: Fractures and Dislocations of the Tarsal Navicular. JAAOS 2016

›Comprehensive review of tarsal navicular fractures

›Rosenbaum AJ, Uhl RL, DiPreta JA: Acute Fractures of the Tarsal Navicular. Orthopedics 2014

›Acute fracture patterns and treatment algorithms

›Webber KJ et al: Navicular Fractures in Elite Athletes - 2025 International Foot and Ankle Sports Consensus. KSSTA 2025

›Current consensus on management in elite athletes

Key evidence

›Stress fracture evidence

›Torg JS et al: Management of Tarsal Navicular Stress Fractures. American Journal of Sports Medicine 2010

›NWB conservative 96% success vs weight-bearing 44% success

›Fowler JR et al: Non-Surgical and Surgical Treatment of Tarsal Navicular Stress Fractures. Sports Medicine 2011

›Surgical vs conservative outcomes

›Attia AK et al: Return to Sport Following Navicular Stress Fracture. International Orthopaedics 2021

›Meta-analysis of 315 fractures, mean return to sport 127 days

›Modica AS, Lucido C, Bitterman AD: Review of Current Management of Navicular Stress Fractures in Athletes. Sports Health 2026

›Most current management review

›Hoenig T et al: Return to Sport Following Low-Risk and High-Risk Bone Stress Injuries. BJSM 2023

›Navicular classified as high-risk bone stress injury

›Imaging guidance

›Smith SE et al: ACR Appropriateness Criteria Acute Trauma to the Ankle. JACR 2020

›Imaging selection guidance

›Khan KM et al: Tarsal Navicular Stress Fracture in Athletes. Sports Medicine 1994

›Landmark descriptive series

›Coris EE, Lombardo JA: Tarsal Navicular Stress Fractures. American Family Physician 2003

Evidence & Review

Evidence & Review