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The Journal of Foot & Ankle Surgery 51 (2012) 209–211

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The Journal of Foot & Ankle Surgery

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Complete Open Dislocation of the Navicular: A Case Report

Harish Rao, MS (Ortho)Professor, Department of Orthopaedics, People’s College of Medical Sciences, Bhanpur, Bhopal, India

a r t i c l e i n f o

Level of Clinical Evidence: 4Keywords:arthrodesiselderlyfracturesurgerytarsaltrauma

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: Harish Rao, MS (O

Orthopaedics, People’s College of Medical Sciences, BE-mail address: harishrao27@gmail.com

1067-2516/$ - see front matter � 2012 by the Americdoi:10.1053/j.jfas.2011.10.033

a b s t r a c t

Complete dislocation of the navicular is rare, and open dislocation even more so. We report a case of a 85-year-old female patient who experienced complete open dislocation of navicular, successfully treated by openreduction and arthrodesis of the naviculocuneiform and calcaneocuboid joints. At 2 years after treatment, thepatient was symptom free and had nearly normal foot function.

� 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.

Midtarsal joint dislocations are rare, and isolated dislocation of thetarsal bone even more so. This is because of the stability conferred bythe geometry and orientation of the tarsal bones in the mid foot thatare held firmly by strong ligaments (1). The navicular bone is thekeystone of the medial longitudinal arch. It is stabilized by dorsal andplantar ligaments, rendering it more prone to fracture than disloca-tion. Isolated dislocation of the navicular bone without fracture of thebody is rare. It has been claimed that dislocation of the navicularwithout associated fracture of the tarsal bones is an anatomicimpossibility (2). A concept of interdependence of the medial andlateral longitudinal columns of the foot in rendering the stability ofthe foot has been proposed in which it has been claimed that isolateddislocation in 1 columnwithout disrupting the bony and ligamentousanatomy of the adjacent column is impossible (3).

We report a rare case of complete open navicular dislocation withcomminuted intra-articular fracture of the calcaneum and associatedsubluxation at the calcaneocuboid joint in an 84-year-old femalepatient who was successfully treated by open reduction, primaryarthrodeses of the naviculocuneiform joints and calcaneocuboid joint,and stabilization using Kirschner wires.

Case Report

An 85-year-old female patient presented to our hospital witha history of being run over by a truck about 2 hours earlier. Shehad a deformed right foot with a lacerated wound 5 cm � 2 cm onthe medial aspect of the mid foot. No neurologic or vascular deficit

rtho), Professor, Department ofhanpur, Bhopal 462001 India.

an College of Foot and Ankle Surgeon

was found. Her navicular was partially exposed. Radiologic exam-ination revealed complete dislocation of the navicular from thetalus and the 3 cuneiform bones, a comminuted intra-articularfracture of the calcaneum, and subluxation at the calcaneocuboidjoint. A medial rotation of 90� was noted in the navicular (Figs. 1and 2).

She was taken for surgery within 6 hours of her injury. The woundwas debrided after thorough surgical cleansing. That the dorsal andplantar ligaments of the navicular were completely torn was deter-mined visually and digitally, with the finding of a discontinuity of thesoft tissues. The talonavicular capsule was partially torn. There wasavulsion of the tibialis posterior slip to the navicular. A reduction ofthe navicular was effected by abducting and pronating the foot;however, the reduction was found to be unstable. Furthermore, onfinding the distal articular cartilage of navicular abraded onmost of itssurface, it was decided to perform arthrodesis of the naviculocunei-form joints. The subchondral bone on the proximal articular surface ofthe cuneiforms was exposed using a curette. The first ray was fixedwith Kirschner wire passing obliquely through the metatarsal head,Lisfranc joint, midtarsal joint, and Chopart’s joint across the ante-roinferior part of the talar head into the body of calcaneum. Thetibialis posterior slip was anchored to the navicular and surroundingsoft tissue. To render stability to the lateral column, it was decided toperform arthrodesis of the fifth ray and to fix it with Kirschner wires.The calcaneocuboid joint was exposed by a shorter Cincinnati inci-sion. The proximal articular cartilage of the cuboid was abraded witha curette to expose the subchondral bone. In a similar manner, thearticular cartilage on the distal calcaneal surface on the major frag-ments was abraded. The fifth ray was fixed with 2 Kirschner wirespassing in opposite directions from the head of the fifth metatarsaland calcaneal tuberosity, respectively. This was deemed necessary,because a single wire through the head of the fifth metatarsal wasinsufficient in rendering stability (Fig. 3).

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Fig. 3. Anteroposterior and lateral postoperative radiographs of ankle showing stabili-zation of medial and lateral columns with Kirschner wires.

Fig. 1. Anteroposterior radiograph showing lateral oblique views of ankle with completedislocation of navicular from talus and cuneiforms with communicated fracture ofcalcaneum with subluxation of calcaneocuboid joint.

H. Rao / The Journal of Foot & Ankle Surgery 51 (2012) 209–211210

The medial wound was debrided and loosely closed with suturesto cover the bone. Regular wound dressing was performed, andbroad-spectrum injectable antibiotics were given initially for 7 daysfollowed by oral antibiotics for another 2 weeks. This was necessary,because it was a road side injury and the wound was severelycontaminated. A posterior below the knee splint was applied forsupport and to rest the foot. Nonweight-bearing ambulation wasstarted on the second day. The Kirschner wires were removed after 1month, and the splinting was continued for another month withnonweight-bearing ambulation. The wounds had completely healedby the end of 1 month. The patient was advised to undergo physio-therapy for the ankle joint and foot. Partial weight bearing was star-ted, with gradual progression to full weight bearing at the end of 4months.

The patient regained a full range of movement at the ankle jointand partial range of motion at the subtalar joint. At the end of 1 year,the patient was comfortable and could ambulate without support.

Fig. 2. Anteroposterior and lateral radiographic views of ankle showing communicatedfracture of calcaneum with subluxation of calcaneocuboid joint.

However, she complained of occasional pain in the midfoot region,especially when walking on an uneven surface. Radiographs showedcomplete fusion of the arthrodesed tarsal joints with osteopenia. Noevidence was found of avascular necrosis of the navicular, and herrange of movement at the ankle and subtalar joints was fully restored(Fig. 4). At 24 months postoperative, we were informed by her rela-tives that she was symptom free and comfortable.

Discussion

Midtarsal joint dislocations are rare, and isolated dislocation oftarsal bones even more so. Various patterns of dislocations of midfoothave been described for their rarity, including calcaneocuboid withfracture of the medial cuneiform (4), calcaneocuboid with naviculo-cuneiform (5), and calcaneocuboid with talonavicular dislocation(6,7). Isolated or complete dislocation of the navicular, with various

Fig. 4. Anteroposterior and lateral postoperative radiographs of ankle at 1 year showingfusion of naviculocuneiform joints and calcaneocuboid joints.

H. Rao / The Journal of Foot & Ankle Surgery 51 (2012) 209–211 211

patterns of associated injuries in the lateral column, or an unstablemidfoot break and significant soft tissue injuries have also beendescribed, including fracture/subluxation of the calcaneocuboid joint(3), fracture of the cuboid (8), fracture of the base of the fifth meta-tarsal (9), fracture of third and fourth metatarsals with fracturedislocation of the calcaneocuboid joint (10), and fracture of the secondto fourthmetatarsals, cuboid, and intermediate cuneiform (11). This isin agreement with the all or none concept of Dhillon and Nagi (3), inwhich injury to either column of the foot cannot occur without dis-rupting the bony or ligamentous anatomy of the adjacent column,emphasizing the interdependence of the medial and lateral columnsof the foot in rendering stability to the foot.

The exact mechanism of injury is not known. Various mechanismshave been postulated. According to Dhillon and Nagi (3), the mecha-nism of injury has been postulated as a severe pronation/abductioninjury causing a break in the medial column at the naviculocuneiformjoint and concurrently a nut cracker-like injury of the lateral column,producing disruption of the calcaneocuboid joint or the tarsometa-tarsal joint. The forefoot can dislocate superolaterally or infer-olaterally, depending on whether the deforming force is plantar ordorsally directed. On relocation of the forefoot, the navicular getsdislocated medially and dorsally or plantarward, depending on thesoft tissue attachment. Another mechanism of injury has beenpostulated by Pathria et al (10) of a complex wringing injury. Also,Dixon (9) proposed a transient midtarsal dislocation, with a concom-itant second direct blow causing dislocation of the navicular. Directtrauma or an indirect torsional injury, producing a severe pronationabduction deforming force to the forefoot can result in such an injury.In our case, we postulated that the mechanism of injury wasa combination of both direct trauma and an indirect deforming forcebyway of pronation and abduction of the forefoot sustained when thepatientwas run over by a slow-moving truck from the lateral tomedialside of the foot that was further accentuated by a fall owing to theimpact. This was evidenced by the lacerated wound over the medialaspect of the foot and comminution of the calcaneum at the distalarticulationwith the cuboid. Immediate reduction and stabilization of

both columns are essential for a successful outcome. In the midfoot,the talonavicular joint and cuboid–fourth and fifth metatarsal jointsare the only joints with significant movement. Thus, these joints mustbe spared fusion because such fusion is not well tolerated by patientsand the mobility is essential for proper functioning of the foot.

The treatment principles of combined midfoot injuries includemaking the correct diagnosis early, maintaining an appropriate lateraland medial column length, maintaining the appropriate relationshipbetween the forefoot and hindfoot to ensure a plantigrade foot,preserving motion in the talonavicular joint and cuboid–metatarsalarticulation if possible, using stable internal fixation to maintain theanatomic reductions or primary arthrodeses, and allowing anadequate period to achieve bone and soft tissue healing (1). Finally,after >2 years follow-up, the successful outcome in our case can beattributed to the prompt treatment and adherence to the principles ofwound management and these principles.

References

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3. Dhillon MS, Nagi ON. Total dislocation of the navicular: are they ever isolatedinjuries? J Bone Joint Surg Br 81-B:881–885, 1999.

4. Kollmannsberger A, De Boer P. Isolated calcaneo-cuboid dislocation: brief report.J Bone Joint Surg Br 71-B:323, 1989.

5. Randall RL, Hall RJ, Slabaugh P. An unusual midfoot dislocation: a case report. AmJ Ortho 26:494–496, 1997.

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8. Berman S. Complete dislocation of tarsal scaphoid. JAMA 83:181–183, 1924.9. Dixon JH. Isolated dislocation of the tarsal navicular (letter). Injury 10:251, 1979.

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