What is the best management approach for a patient with a comminuted navicular fracture involving the talonavicular and naviculocuneiform joints, with associated avulsion fracture and suspected subchondral fracture?

Management of Severely Comminuted Navicular Fracture with Articular Involvement

This severely comminuted navicular fracture involving both the talonavicular and naviculocuneiform joints requires urgent open reduction and internal fixation (ORIF) within 24-48 hours to restore articular congruity and preserve the medial column of the foot. 1, 2

Immediate Surgical Planning

Surgical intervention is mandatory for this injury pattern because:

• Large, significantly displaced intra-articular navicular fractures require ORIF to restore anatomic joint surfaces 1
• Comminuted fractures involving the body with articular disruption correlate directly with poor outcomes if not anatomically reduced 2
• The talonavicular joint must be preserved to maintain motion and prevent later fusion 1

Fracture Classification and Prognosis

This injury represents a Type III fracture in modern classification systems, characterized by multifragmentary body fractures with talonavicular joint damage 3, 4. This classification strongly correlates with:

• Lower functional scores (VAS-FA correlation r = -0.663) 3
• Higher rates of talonavicular osteoarthritis (correlation r = 0.600) 3
• Only 50% achieve satisfactory reduction in Type-3 comminuted patterns 2

The associated suspected talar fracture and middle cuneiform avulsion indicate a Type 5 injury pattern with midtarsal joint disruption and medial column crushing 4, which carries significant long-term morbidity risk.

Surgical Technique Requirements

Critical Technical Goals

• Achieve anatomic reduction of >60% of joint surfaces in both AP and lateral planes, as this directly correlates with clinical outcome 2
• Restore talonavicular joint congruity as the primary objective 1
• Preserve medial column length and stability 1

Fixation Strategy for Comminuted Patterns

Use supplementary transverse wire fixation through the cuneiforms and cuboid in combination with screws 5. This technique is specifically designed for severe comminution where:

• Standard wire fixation through comminuted navicular fragments is ineffective 5
• Wires placed through intact adjacent bones (cuneiforms, cuboid) provide stable ancillary fixation 5
• Primary screw fixation addresses larger fragments while wires maintain overall reduction 5

Surgical Approach Considerations

• Balance limited exposure to preserve blood supply against adequate visualization for anatomic reduction 1
• The navicular has tenuous vascularity with high risk of avascular necrosis 1
• Exposure must be extensive enough to permit rigid internal fixation 1

Management of Associated Injuries

Naviculocuneiform Joint

• This joint can be fused if necessary to improve fixation or enhance navicular vascularity 1
• Stability is more critical than motion at this articulation 1
• Consider primary fusion if severe comminution prevents stable reconstruction 1

Middle Cuneiform Avulsion

• Address during primary surgery if fragment is large enough for fixation 4
• Small avulsions may be excised if they don't compromise stability 4

Suspected Talar Fracture

• Obtain dedicated CT imaging preoperatively to fully characterize this injury 6
• CT demonstrates occult talar fractures in 78% sensitivity compared to radiographs 6
• Talar involvement significantly worsens prognosis and may require separate fixation 3

Adjunctive Measures

Bone Grafting

• Plan for early bone grafting in comminuted patterns 1
• Consider at index procedure or early revision if reduction gaps exist 1

External Fixation

• May be useful as temporary stabilization if soft tissue precludes immediate definitive fixation 1
• Can supplement internal fixation in severe comminution 1

Postoperative Protocol

Weight-Bearing

• Prolonged protected non-weight-bearing for minimum 8-12 weeks 1, 2
• Radiographic healing occurs at average 8.5 weeks 2
• Premature loading risks loss of reduction in comminuted patterns 1

Range of Motion

• Initiate early postoperative range of motion of the talonavicular joint 1
• This preserves joint function while maintaining protected weight-bearing 1

Monitoring

• Serial radiographs every 2-3 weeks to assess maintenance of reduction 2
• Watch for avascular necrosis development (may appear months postoperatively) 1

Expected Outcomes and Counseling

Provide aggressive patient counseling regarding severity and long-term implications 1:

• Only 67% achieve good results even with optimal treatment 2
• 14% have poor outcomes despite surgery 2
• Talonavicular osteoarthritis develops in most patients (grade 1-4 in 79% at midterm follow-up) 3
• Comminuted Type III patterns have significantly worse functional scores than simple fractures 3
• Risk of avascular necrosis, nonunion, and eventual need for fusion 1

Critical Pitfalls to Avoid

• Do not attempt closed treatment - displacement and articular involvement mandate surgery 1, 2
• Do not delay surgery - early intervention improves reduction success 2
• Do not use standard wire fixation alone through comminuted fragments - it will fail 5
• Do not sacrifice talonavicular joint motion unless absolutely necessary 1
• Do not allow early weight-bearing - this fracture requires prolonged protection 1