Navicular Case study

Question 1

What is post-static pain?

Answer 1

pain after you get up initially, however after a little while the pain subsides and becomes less noticeable.

Question 2

is bone pain similar to post-static pain?

Answer 2

NO! Bone pain is more constant and will hurts when you start and activity and continues to be more and more bothersome the more you engage in that activity.

Question 3

HPI of case study…

Answer 3

pain 5/10 and most severe during track.
metatarsus adductus, mild equinas ( compensates by pronating subtalor joint or hyperextended knees)
mild pain with palpation of sinus tartsi of left foot (The tarsal sinus (or sinus tarsi) is a cylindrical cavity located between the talus and calcaneus on the lateral aspect of the foot.)

Question 4

What is the N sign?

Answer 4

tenderness along middle aspect of the navicular bone on dorsal side.

Question 5

testing done… bone scan

Answer 5

bone scan: injection of radioactive dye. lights up due to high density of bone crystals. looks at pattern of uptake of Technesium 99.
Phases:
1. angiogram phase. immediate uptake observed
2. blood pool
3. bone phase ( 3-4 hours- this is where ppl are most interested)
4. late phase: no one does 24 hours.
possible results: no uptake.
positive tests: bone tumor ( bone turnover), infection, stress reaction detected, metabolic bone disorder (gout) and growth plates not completely fused.

Question 6

testing done… CT scan

Answer 6

this detects a small crack. imaging done in 2-5 mm cuts- so we can see into the bone more deeply and get a more detailed picture.

Corticol - the bone is WHITE

CT is a better tool for assessing fractures than XR… esp if they might be subtle fractures.

Question 7

tests done… XR

Answer 7

no fracture observed, no sharp edges. accessory bone in area of the sinus tarsi, which can cause impingement and be painful.

Question 8

MRI imaging…

Answer 8

magnetic resonance imaging.
corticol bone = BLACK
high signal intensity of the navicular: due to high water content from inflammation and swelling the navicular bone appeared bright white… high signal.
this DOES NOT show subtle fractures as well as the CT.
Dr. yoho went overboard in ordering here. good blood flow indicated however?

Question 9

What are navicular fractures so troublesome?

Answer 9

lack of rich blood supply
often cause the bone to die- avascular necrosis
applying bones across can be tricky to secure/place
within the case- his medial side was thicker than the lateral side… hmm - interesting.

Question 10

what is the protocol for grade 3 navicular bone stress reactions?

Answer 10

non weight bearing case cast- CAM boot.

Question 11

what cause navicular fractures most often?

Answer 11

seen in athletes, who endure long durations of strenuous activity. demands of body cannot keep up - causing bone to breakdown rather than build up. bone becomes overwhelmed and equilibrium not kept. bone overload, unable to remodel at rate their is destruction.

Question 12

How to patient’s present who have navicular fractures?

Answer 12

They will have a positive N sign- however this is not a technical/highly regarded test.
no exterior swelling really noted, no redness.
vague symptoms
very challenging diagnosis.
2nd most common stress fracture ( 1st being metatarsal)

Question 13

what are some complications involved with NV fractures?

Answer 13

there is delayed treatment and healing oftentimes.

can result in post-traumatic arthritis.

Question 14

what are predisposing factors to NV fractures?

Answer 14

high arch ( cavus foot)
the overall shape of the navicular ( case patient had a thicker medial aspect)
ankle equinus
short first metatarsal
metatarsus adductus