PMC8219441_01
(a) Initial AP X-ray of the left foot demonstrating subtle talonavicular dislocation, read as negative by radiology. (b) Initial lateral X-ray of the left foot demonstrating subtle talonavicular dislocation, read as negative by radiology.
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fig1
Initial plain X-rays of the foot evaluated by orthopaedics demonstrated a navicular fracture with a medial dislocation of the navicular on the talus (Figures 1(a) and 1(b)).
(a) 3D CT scan demonstrating swivel injury, comminuted fracture of the navicular and cuboid bone, and calcaneocuboid joint subluxation. (b) 3D CT scan from medial viewpoint showing the medial dislocation of the talonavicular joint. (c) Sagittal CT cut of the left foot showing both talonavicular and subtle calcaneocuboid joint subluxations. (d) Axial cut of the CT scan showing medial dislocation of the talonavicular joint left foot; note the navicular fracture fragment that remained in the anatomic position; this "constant fragment" received screw fixation to aid in reconstruction of the navicular bone.
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fig2
An impacted fracture of the anterior calcaneal process was also seen with a comminuted cuboid fracture and a third metatarsal fracture (Figure 2). In addition, the calcaneocuboid and subtalar joints were subluxed (Figures 2(a) and 2(c)).
(a) Intraoperative image showing reduction after open treatment and direct pressure on the navicular bone to hold it reduced; the red line outlines both the navicular and talus bones at the talonavicular joint (TN joint is reduced). (b) Intraoperative image showing the talonavicular joint again with new dislocation after letting pressure off of the foot, demonstrating the unstable nature of the injury; the red line outlines both the navicular and talus bones at the talonavicular joint (TN joint is unreduced).
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fig3
Reduction was aided with direct visualization of the talonavicular joint, and direct pressure on the navicular bone with forefoot abduction achieved the final reduction (Figure 3(a)). However, as soon as forefoot abduction pressure was released, the joint would redislocate (Figure 3(b)).
(a, b) Intraoperative images demonstrating the insertion of K-wires to hold the talonavicular joint reduction and addition of 2.7 mm screws in the "constant fragment" in order to reconstruct the anatomy of the navicular; the K-wires help to keep dislocation forces off of the screw fixation to avoid failure of the navicular screw fixation.
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fig4
Due to this instability, K-wire stabilization was used to hold the navicular fracture and talotarsal reduction (Figures 4(a)and 5(b)). Fixation was then performed with two fully threaded 2.7 mm screws to aid in navicular reduction (Figures 4(b) and 5(a)).
(a, b) Intraoperative images demonstrating the insertion of K-wires to hold the talonavicular joint reduction and addition of 2.7 mm screws in the "constant fragment" in order to reconstruct the anatomy of the navicular; the K-wires help to keep dislocation forces off of the screw fixation to avoid failure of the navicular screw fixation.
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fig5
Due to this instability, K-wire stabilization was used to hold the navicular fracture and talotarsal reduction (Figures 4(a)and 5(b)).
(a) 12-week follow-up with adduction stress of the forefoot. Intraoperative images of the foot showing normal navicular and talonavicular joint radiography and stability with real-time stress radiographs after complete healing and hardware removal; red lines demonstrate the joint surface of the talus and navicular at the talonavicular joint. (b) 12-week follow-up without adduction stress of the forefoot. Intraoperative images of the foot showing normal navicular and talonavicular joint radiography and stability with real-time stress radiographs after complete healing and hardware removal; red lines demonstrate the joint surface of the talus and navicular at the talonavicular joint.
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fig6
Stability was based on the findings that there was no incongruity when compared with the opposite foot during intraoperative stress radiography (Figures 6(a) and 6(b)).