Dr. Amol Saxena, DPM
Palo Alto Foundation
Medical Group
Dept. of Sports Medicine
3rd Floor, Clark Building
795 El Camino Real
Palo Alto, CA 94301
Office: 650-853-2943
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Dr. Amol Saxena, DPM


Results of Treatment of 22 Navicular Stress Fractures and a New Proposed Radiographic Classification System

Amol Saxena, DPM., FACFAS*
Brian Fullem, DPM
David Hannaford, DPM.

* Address correspondence to:

Department of Sports Medicine
Palo Alto Medical Foundation
795 El Camino Real
Palo Alto, CA 94301


Twenty-two navicular stress fractures sustained during athletic activity were retrospectively reviewed for return to activity time and the appearance of fracture pattern on computerized tomography. There were 1 0 females and nine males, with the average patient age being 2 7.2 years. Three patients sustained bilateral injuries at separate times. Average follow-up was 36.5 months. Nine patients underwent open reduction, internal fixation (some with bone grafting); this group's average return to activity (RTA) was 3.1 ± 1.2 months (range, 1.5-5 months). Thirteen patients treated conservatively had an average return to activity of 4.3 ± 2.8 months (range, 2-13 months). The difference between the two groups' RTA was significant (p = .02). Eleven patients utilized pulsed electromagnetic fields (PEMF) and had an average RTA of 4.2 ± 3.4 months, 27.3% of those patients with PEMF also had surgery. Two conservatively treated fractures that took 5 and 8 months to RTA, respectively, re-fractured during the treatment process. Retrospective review showed CT fracture patterns in the frontal plane that were classified as: dorsal cortical break (type /), fracture propagation into the navicular body (type //), and fracture propagation into another cortex (type ///). This is a proposed classification system. It includes modifiers "A" (avascular necrosis of a portion of the navicular); "C" (cystic changes of the fracture), and "S" (sclerosis of the margins of the fracture), the latter of which was most common in our series, particularly in continually symptomatic patients. Type / fractures were more likely to receive conservative treatment (p = .02) and type /I/ fractures took significantly longer to heal than types / and // (p values .001 and .01, respectively.) Type I and // injuries had an average RTA of 3.0 and 3.6 months, respectively. Type /// injuries had an average PTA of 6.8 months. Based on our findings, we recommend surgery for patients with these modifiers, particularly with type // and /I/ injuries. Conservative treatment may be prolonged, and requires at least 6 weeks of nonweightbearing in a below-knee cast boot to be successful. (The Journal of Foot & Ankle Surgery 39(2):96-103, 2000)

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