Fixation across these joints is often removed once healing has occurred in the traumatized foot. Temporary spanning fixation of the talonavicular and calcaneocuboid joint in the setting of trauma will not be durable and is often removed once healing of the traumatized foot has occurred.įixation from the 4th or 5th metatarsals into the cuboid also restricts normal foot motion and is not well tolerated. Mobility at the transverse tarsal joint is necessary for normal gait, and fusions are not well tolerated. Hindfoot valgus “unlocks” the transverse tarsal joint. This complex is stiff with hindfoot varus, as in the toe-off phase of gait, and provides a rigid lever for ambulation. The transverse tarsal, or Chopart, joint is formed by the talonavicular and calcaneocuboid joints. The 2nd metatarsal meets the middle cuneiform in a rigid joint, more proximal than the 1st and 3rd joints, and is referred to as the “keystone” of the midfoot. The cuneiforms articulate with the navicular proximally, 1st-3rd metatarsal bases distally, and cuboid laterally (with lateral or 3rd cuneiform). These joints are more mobile than the more medial midfoot joints, as they are analogous to the ring and little finger of the hand, helping provide some measure of “grip” of the ground. Articulation distally is with the 4th and 5th metatarsal bases. The cuboid articulates in a mobile relationship with the anterior process of the calcaneus proximally. The articulation distally is with 3 cuneiforms, where stability is more important than flexibility. The navicular articulates in a mobile relationship with the talus proximally. It forms the transverse arch of the foot and is also part of the longitudinal arch. The midfoot includes 5 tarsal bones: Navicular, cuboid, and 3 cuneiforms (medial, middle, and lateral). Injury will not infrequently lead to insufficiency of the lateral column of the foot, such that treatment will often require some distraction to regain that length. There are rarer injuries still, and they will rarely occur in isolation. Vigilance is required either way, as it can be difficult to get long-term nonunions to heal. Many stress fractures can be managed nonoperatively, although some will require surgery. As a result, stiffness is often a concern after these injuries. Some joints may need to be temporarily spanned in order to provide sufficient stability for the injury to heal. High-energy injuries will require a plan that takes into account all associated injuries, understanding that many of the joints in the hindfoot and midfoot work in tandem, such that injury to one will directly affect the other. These injuries are by far the least severe of the 3. Three types of navicular fractures generally occur: Avulsion fractures, high-energy fractures with other associated injuries, and stress fractures.Īvulsion fractures can generally be treated nonoperatively, except in those cases in which the fragment is large enough to warrant open reduction and internal fixation.
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