Navicular Fracture Mapping: A New Perspective on Fracture Patterns and Surgical Strategies

Navicular Fracture Mapping: A New Perspective on Fracture Patterns and Surgical Strategies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Navicular Fracture Mapping: A New Perspective on Fracture Patterns and Surgical Strategies Quentin DA CUNHA, Vincent STEIGER, Clément MARC, Louis RONY, Guillaume DAVID This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7500806/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Oct, 2025 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted 7 You are reading this latest preprint version Abstract Background: Navicular fractures are rare and pose significant surgical challenges. This study aimed to define the location and frequency of fracture lines using both two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) mapping. We hypothesized that fracture mapping could reveal constant fragments, as well as patterns of impaction and comminution, to help optimize surgical management. Methods: A retrospective analysis of CT scans from 44 patients was performed. Fractures were classified according to the Sangeorzan system. Three-dimensional reconstructions were used to identify key fracture patterns, zones of impaction, and the presence of a constant plantar fragment, based on a 360-degree quadrant mapping approach. Results: Type I fractures (n = 8) were simple transverse fractures with no reproducible pattern. Type II fractures (n = 10) followed an oblique dorsolateral-to-plantar-medial trajectory, with 43% showing impaction in the lateral quadrant. Type III fractures (n = 26) were associated with comminution in 96% of cases and impaction in 81%, with fracture lines converging at the talonavicular joint. A constant plantar fragment was identified in 56% of Type II and 73% of Type III fractures. Conclusion: 3D navicular fracture mapping may improve understanding of fracture morphology and injury mechanisms. By identifying consistent fracture features, this technique may assist in preoperative planning and inform reduction and fixation strategies. Level of evidence : IV Fracture midfoot mapping navicular tarsal 3D CT Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Fractures of the tarsal navicular are uncommon, accounting for approximately 35.5% of midfoot injuries and 5% of all foot injuries.[ 1 ] Motor vehicle collisions (MVCs) are the most common cause, as a high-energy mechanism is typically required to generate the degree of impaction and distraction necessary to disrupt the navicular and adjacent structures. These forces often propagate along the medial column and may also affect the lateral column, leading to a high incidence of associated injuries. Evans et al. reported a 62% incidence of concomitant midfoot and hindfoot injuries on the same side.[ 2 ] This susceptibility is due to the complex network of plantar and dorsal ligaments and the compact nature of the tarsal bones, which together confer significant structural rigidity to the midfoot. The interdependence between the medial and lateral columns of the foot has been likened to the pelvic ring, where injury to one side often implies compromise of the other.[ 3 ] The navicular bone plays a key role in hindfoot motion and gait. Anatomical reduction of this joint is critical for preserving mobility and preventing post-traumatic osteoarthritis. As the keystone of the medial longitudinal arch, the navicular contributes to maintaining the length and alignment of the medial column; shortening following fracture can result in hindfoot varus and forefoot abduction. Navicular fractures are commonly classified into three types based on fracture pattern and joint involvement.[ 4 ] Type I and II fractures tend to preserve medial foot alignment, whereas Type III fractures are frequently associated with lateral comminution and displacement. This classification system has prognostic value for predicting the difficulty of reduction and potential clinical outcomes ( Fig. 1 ). Talar-navicular fractures remain difficult to manage, particularly in polytrauma patients, due to their association with high-energy trauma and the resulting long-term morbidity.[ 5 ] Preoperative planning is essential, and understanding common fracture patterns is crucial to guide open reduction and internal fixation (ORIF). The presence of a constant plantar fragment, as described by Cronier et al., may serve as a reliable landmark for reduction in complex comminuted cases.[ 6 ] Three-dimensional (3D) reconstruction and fracture mapping techniques have already been validated in other anatomical regions, such as the calcaneus and acetabulum, to identify consistent fracture lines and constant fragments.[ 7 , 8 ] However, such methodologies have not yet been systematically applied to navicular fractures. The aim of this study was to determine whether 3D fracture mapping of navicular fractures could identify constant fragments, as well as zones of impaction and comminution, to support improved reduction strategies and fixation, while preserving the delicate osseous and vascular anatomy of the navicular. Materials and Methods Study Design and Patient Cohort This was a single-center retrospective study conducted at a trauma center, following approval by the institutional review board. All patients presenting with an acute navicular fracture between 2007 and 2023 were included. Patient demographics including age, mechanism of injury, laterality, presence of an open fracture, and associated fractures of the foot and ankle were recorded. Exclusion criteria included age under 18 years and incomplete or non-assessable radiographic or CT data. All included CT scans encompassed the entire foot, from forefoot to hindfoot, with a maximum slice thickness of less than 3 mm. Scans were obtained pre- and postoperatively and accessed via the hospital’s Picture Archiving and Communication System (PACS). Fractures were classified according to the Sangeorzan classification.[ 4 ] CT Analysis and 3D Modeling Raw CT data were exported as DICOM (Digital Imaging and Communications in Medicine) files from PACS. Axial-plane data were imported into 3D Slicer (Brigham and Women’s Hospital; open-source software) to generate individual project files. Fractures were analyzed in axial, sagittal, and coronal planes simultaneously. To isolate the navicular bone and its fragments from surrounding tarsal structures, segmentation was performed using two templates: one for the navicular and another for adjacent bones. Articular surfaces and fragment boundaries were highlighted across at least three CT slices per anatomical plane. The segmented navicular was then converted into a 3D model and exported as an STL file for further analysis. 3D Fracture Mapping Fracture mapping methods followed standardized protocols described by Cole et al. and Xie et al.[ 9 , 10 ] Each STL file was imported into Blender (Blender Foundation; open-source software), where the main fragments were virtually reduced in three spatial dimensions. Fragment alignment was performed using anatomical landmarks, including the medial tuberosity, the inferior groove for the tibialis posterior tendon, the perforated dorsal cortex, and the lateral cuboid articular surface. Each reconstructed fracture pattern was superimposed onto a template model of an uninjured navicular using a specific ICP (Iterative Closest Point) alignment add-on, based on the aforementioned landmarks. Left-sided fractures were mirrored to match the right side for standardization. Once proper anatomical alignment was confirmed (after a minimum of 50 iterations), fracture lines were manually traced as smooth curves on the template surface. Superimposing all individual fracture lines created a frequency-based fracture line map. In addition, zones of impaction and comminution were identified for each case, allowing the generation of corresponding 3D heat maps. These heat maps used a color gradient (from blue to red) to reflect the frequency of involvement. Impaction and comminution zones were analyzed according to four quadrants in a posteroanterior view: superomedial, superolateral, inferomedial, and inferolateral ( Fig. 2 ). Data Analysis Statistical analyses were performed using R software (version 3.6.1; R Foundation for Statistical Computing). Qualitative variables were expressed as counts and percentages. Quantitative variables were presented as means with standard deviations (SD). Comparisons of quantitative variables were made using Student’s t-test, with statistical significance set at p < 0.05. Confidence intervals were reported at the 95% level. Results Patient characteristics A total of 54 navicular fractures were initially identified. Ten patients were excluded due to incomplete radiographic records. The final cohort consisted of 44 patients, of whom 36 (82%) were male and 8 (18%) were female, with a mean age of 34 years (range, 15–74). According to the Sangeorzan classification, 8 patients (18%) had Type I fractures, 10 (22%) had Type II fractures, and 26 (60%) had Type III fractures. Most injuries occurred during road traffic accidents (63.6%). Four patients (9.1%) had open fractures. One patient presented with a neurovascular injury that led to mid-term amputation. Associated injuries were common, found in 79.5% of cases, typically involving at least one of the three regions of the foot (forefoot, midfoot, or hindfoot). Patient demographics and fracture characteristics are summarized in Table 1 . Table 1 – Patient demographics and Fracture characteristics (N = 44)*Only one case of a bilateral type 3 navicular fracture is represented here as 1 patient but in both sections into the laterality. **The values are given as the mean, with the range in parentheses. TYPE 1 TYPE 2 TYPE 3 Size (nbr. [%]*) 8 (18) 10 (22) 26 (60) Age (years)** 39 (23–74) 27 (15–45) 33 (16–58) Sex (nbr. [%]) Male 5 (62) 9 (90,0) 22 (85) Female 3 (38) 1 (10,0) 4 (15) Laterality (nbr. [%]) Right 6 (75) 4 (40) 14 (52) Left 2 (25) 6 (60) 13 (48) Skin coverage (nbr. [%]) Open 1 (13) 0 (0) 3 (12) Closed 7 (87) 10 (100) 23 (88) Concomitant injuries (nbr. [%]) NO 2 (25) 2 (20) 5 (19) YES 6 (75) 8 (80) 21 (81) Forefoot 2 2 6 Midfoot 3 7 12 Hindfoot 4 3 9 Others 5 2 12 Treatments Orthopedic 5 (63) 4 (40) 2 (8) Surgical 3 (37) 6 (60) 24 (92) Plating 0 4 20 Screw 3 3 5 K-wire 1 0 2 other 1 0 0 Fracture characteristics and management Type I fractures Type I fractures accounted for 18% of the cohort (n = 8). These were simple transverse fractures without a consistent or reproducible pattern. No impaction or comminution zones were identified. Most cases were managed nonoperatively (5 patients, 62.5%). Surgical fixation was reserved for fractures with large or significantly displaced fragments. Type II fractures Type II fractures represented 22% of the cohort (n = 10). Fracture lines followed an oblique dorsolateral-to-plantar-medial trajectory. Impaction zones were predominantly located along the lateral aspect of the talonavicular joint. Comminution was primarily concentrated in the superolateral quadrant of the navicular. Treatment was tailored according to the degree of displacement and comminution. Surgical management was performed in 60% of cases, using screws or plates depending on fragment size and location. Type III fractures Type III fractures were the most common, representing 60% of the cohort (n = 26). These injuries were frequently associated with additional midfoot (46%) or hindfoot (34%) fractures. In all Type III cases, a plantar region of the navicular remained intact, corresponding to what we termed the lateral plantar fragment. This constant fragment was present in 73% of Type III and 56% of Type II fractures. Impaction zones consistently converged at the central portion of the talonavicular joint. Comminution was primarily located along the inferolateral aspect of the navicular and often extended toward the cuboideonavicular joint. An overview of these findings is presented in Fig. 3 . Discussion Using 3D fracture mapping techniques, we identified consistent fracture patterns in both Type II and Type III navicular fractures. These included recurrent zones of impaction and comminution, as well as the frequent presence of a constant plantar fragment. Type I fractures did not demonstrate any reproducible pattern. This may reflect true variability in morphology or could be due to the limited sample size in this subgroup. In Type II fractures, the predominant fracture line followed a sagittal trajectory from the dorsolateral to the plantar-medial corner, typically resulting in a large medial fragment. This finding reinforces the fracture pathway described in the Sangeorzan classification and supports currently established reduction and fixation strategies. In Type III fractures, analysis of all fracture lines revealed three primary fragments: a consistent plantar lateral fragment that remained uninvolved, a dorsolateral fragment, and a dorsomedial fragment. Cronier et al. attributed the preservation of the plantar fragment to the strength of the inferior calcaneonavicular (bifurcate) ligament, which anchors the fragment to the anterior process of the calcaneus.[ 6 ] This pattern supports the designation of a "constant fragment," analogous to the sustentaculum tali in calcaneal fractures. Rockett et al. also observed this fragment in CT-based analyses and incorporated it into their reduction strategy.[ 11 ] 3D mapping of impaction and comminution zones revealed consistent involvement of the dorsolateral quadrant. These areas varied in severity depending on fracture type, with more extensive damage observed in Type III fractures. This distribution appears to support the injury mechanism proposed by Rockett et al., particularly in Type III injuries, where axial loading of the talar head on a pronated hindfoot may exacerbate impaction and comminution.[ 11 ] The potential clinical value of 3D fracture mapping lies in its capacity to improve understanding of navicular fracture morphology, offering a reproducible framework for anticipating fragment configuration and zones of comminution. This is relevant because restoring talonavicular congruity and medial column length is critical for achieving favorable outcomes.[ 12 ] Despite applying these principles, secondary osteoarthritis remains common. In the series by Coulibaly et al., 85.4% of patients developed osteoarthritis following surgical treatment.[ 13 ] Fracture mapping may help surgeons anticipate the location of key fragments and tailor the surgical approach accordingly. This information may support decision-making around incision placement and exposure, with the aim of balancing adequate visualization with preservation of vascular integrity. Given the navicular’s limited blood supply, protecting its biological environment is essential to reduce the risk of avascular necrosis. DiGiovanni et al. emphasized the importance of an approach that permits simultaneous access to both the talonavicular and naviculo-cuneiform joints, while minimizing periosteal, capsular, or ligamentous stripping.[ 3 ] Respectful placement of plates and screws is also recommended to avoid devascularization. Sangeorzan et al. suggested that at least 60% of the talonavicular joint surface must remain intact to prevent postoperative subluxation.[ 4 ] In our series, comminution was consistently located in the dorsolateral quadrant, an area often difficult to anatomically reduce, which may contribute to lateral subluxation of the talar head. Anatomical reduction of the less comminuted medial portion onto the plantar fragment, anchored to the calcaneal beak, may act as a stabilizing platform and help limit medial displacement of the navicular body. In our practice, the presence of a plantar fragment is taken into consideration during ORIF for Type III, and to some extent Type II fractures, as it may serve as a stable platform for repositioning the main navicular body. ( Fig. 5 , 6 ) A prospective clinical study would be required to determine whether this concept results in improved outcomes. This study has several limitations. It was retrospective and conducted at a single center. The use of the Sangeorzan classification, although widely adopted, may also be questioned, as it does not always capture medial border disruption or forefoot angulation. Schmid et al. have proposed an alternative classification based on the extent of talonavicular joint damage as visualized on preoperative CT scans, which may provide additional clinical relevance.[ 14 ] Conclusion This study illustrates the potential value of 3D fracture mapping in improving the understanding of navicular fracture morphology and injury mechanisms. By identifying consistent fracture patterns and key fragments, mapping may assist in refining surgical strategies. Optimizing reduction while preserving the bone’s biological integrity remains a central goal, in line with established AO principles. Declarations Funding Statement The authors declare that no funding was received for the conduct of this study. Author Contribution QDC : redacted the manuscriptVS : carried out data collectionCM : prepared figures and tableLR : carried out statistical analysesGD : proofread and corrected the manuscript References Marshall D, MacFarlane RJ, Molloy A, Mason L (2020) A review of the management and outcomes of tarsal navicular fracture. Foot Ankle Surg 26:480–486. https://doi.org/10.1016/j.fas.2019.05.020 Evans J, Beingessner DM, Agel J, Benirschke SK (2011) Minifragment plate fixation of high-energy navicular body fractures. Foot Ankle Int 32:S485-492. https://doi.org/10.3113/fai.2011.0485 DiGiovanni CW (2004) Fractures of the navicular. Foot Ankle Clin 9:25–63. https://doi.org/10.1016/S1083-7515(03)00173-6 Sangeorzan BJ, Benirschke SK, Mosca V, et al (1989) Displaced intra-articular fractures of the tarsal navicular. J Bone Joint Surg Am 71:1504–1510 Richter M, Thermann H, Wippermann B, et al (2001) Foot fractures in restrained front seat car occupants: a long-term study over twenty-three years. J Orthop Trauma 15:287–293. https://doi.org/10.1097/00005131-200105000-00009 Cronier P, Frin J-M, Steiger V, et al (2013) Internal fixation of complex fractures of the tarsal navicular with locking plates. A report of 10 cases. Orthop Traumatol Surg Res 99:S241–S249. https://doi.org/10.1016/j.otsr.2013.03.001 Cho J-W, Cho W-T, Sakong S, et al (2021) Mapping of acetabular posterior wall fractures using a three-dimensional virtual reconstruction software. Injury 52:1403–1409. https://doi.org/10.1016/j.injury.2021.03.054 Guillaume D, Joshua A P, Remi DF, Cyril M (2024) Endopelvic Zones and Constant Fragment Mapping in Acetabular fractures. Injury 111652. https://doi.org/10.1016/j.injury.2024.111652 Cole PA, Mehrle RK, Bhandari M, Zlowodzki M (2013) The Pilon Map: Fracture Lines and Comminution Zones in OTA/AO Type 43C3 Pilon Fractures. J Orthop Trauma 27:e152–e156. https://doi.org/10.1097/BOT.0b013e318288a7e9 Xie X, Zhan Y, Dong M, et al (2017) Two and Three-Dimensional CT Mapping of Hoffa Fractures. J Bone Jt Surg 99:1866–1874. https://doi.org/10.2106/JBJS.17.00473 Rockett MS, Brage ME (1997) Navicular body fractures: computerized tomography findings and mechanism of injury. J Foot Ankle Surg Off Publ Am Coll Foot Ankle Surg 36:185–191. https://doi.org/10.1016/s1067-2516(97)80114-7 Clements JR, Dijour F, Leong W (2018) Surgical Management Navicular and Cuboid Fractures. Clin Podiatr Med Surg 35:145–159. https://doi.org/10.1016/j.cpm.2017.12.001 Coulibaly MO, Jones CB, Sietsema DL, Schildhauer TA (2015) Results and complications of operative and non-operative navicular fracture treatment. Injury 46:1669–1677. https://doi.org/10.1016/j.injury.2015.04.033 Schmid T, Krause F, Gebel P, Weber M (2016) Operative Treatment of Acute Fractures of the Tarsal Navicular Body: Midterm Results With a New Classification. Foot Ankle Int 37:501–507. https://doi.org/10.1177/1071100715624208 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Oct, 2025 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted Editorial decision: Accepted 27 Sep, 2025 Reviews received at journal 21 Sep, 2025 Reviewers agreed at journal 11 Sep, 2025 Reviewers invited by journal 06 Sep, 2025 Editor assigned by journal 01 Sep, 2025 Submission checks completed at journal 01 Sep, 2025 First submitted to journal 31 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7500806","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":513890145,"identity":"f8bef65c-9777-49f5-88b8-aabb24eee317","order_by":0,"name":"Quentin DA CUNHA","email":"","orcid":"","institution":"Centre Hospitalier Universitaire d'Angers","correspondingAuthor":false,"prefix":"","firstName":"Quentin","middleName":"DA","lastName":"CUNHA","suffix":""},{"id":513890147,"identity":"30dd511e-6697-4674-9fd9-005df4b3b62c","order_by":1,"name":"Vincent STEIGER","email":"","orcid":"","institution":"Centre Hospitalier Universitaire d'Angers","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"","lastName":"STEIGER","suffix":""},{"id":513890149,"identity":"7a90150a-d213-4ee5-b689-82aee55e41e8","order_by":2,"name":"Clément MARC","email":"","orcid":"","institution":"Centre Hospitalier Universitaire d'Angers","correspondingAuthor":false,"prefix":"","firstName":"Clément","middleName":"","lastName":"MARC","suffix":""},{"id":513890150,"identity":"6276fc2d-5646-4c58-8c6d-57dd4fe6a30f","order_by":3,"name":"Louis RONY","email":"","orcid":"","institution":"Centre Hospitalier Universitaire d'Angers","correspondingAuthor":false,"prefix":"","firstName":"Louis","middleName":"","lastName":"RONY","suffix":""},{"id":513890151,"identity":"6a554f21-60e3-47bf-96ec-8562618866cf","order_by":4,"name":"Guillaume DAVID","email":"data:image/png;base64,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","orcid":"","institution":"Centre Hospitalier Universitaire d'Angers","correspondingAuthor":true,"prefix":"","firstName":"Guillaume","middleName":"","lastName":"DAVID","suffix":""}],"badges":[],"createdAt":"2025-08-31 13:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7500806/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7500806/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00590-025-04550-8","type":"published","date":"2025-10-07T15:57:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91197713,"identity":"12c2c7dc-e454-4493-9bd9-2635da93329b","added_by":"auto","created_at":"2025-09-12 15:09:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":858929,"visible":true,"origin":"","legend":"\u003cp\u003eSangeorzan’s classification of navicular fracture. Type 1 = the primary fracture line is transverse in coronal plane. Type 2 = Fractures traverses from dorsolateral to plantar-medial across the navicular body. Type 3 = fracture is essentially with central or lateral comminution, with or without a subluxation or disruption.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7500806/v1/8e634153d8975a259cb8bf24.png"},{"id":91196154,"identity":"4c9d9460-4524-43c4-b85e-9322f50aa088","added_by":"auto","created_at":"2025-09-12 15:01:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1474039,"visible":true,"origin":"","legend":"\u003cp\u003eThe 3D method of navicular fracture mapping. Here, an example of Sangeorzan’s type 3 body navicular fracture, with a partial reduction to maintain the comminution area (\u003cstrong\u003eA\u003c/strong\u003e). After obtaining the most perfectible overlapping on the template model, the fracture lines was drawn with a red line (\u003cstrong\u003eB and C\u003c/strong\u003e) and the impaction zone was identified by the same model (black lines) and unified on a heat map (\u003cstrong\u003eD\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7500806/v1/56a43663570d43bda99baabf.png"},{"id":91196156,"identity":"99d6b471-68e3-46ad-a096-a6c56f872bef","added_by":"auto","created_at":"2025-09-12 15:01:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1890339,"visible":true,"origin":"","legend":"\u003cp\u003eFracture mapping, impaction and comminution zones for each type\u003cstrong\u003e. \u003c/strong\u003eThe frequency of impactions and comminutions is represented using a heatmap, with a scale ranging from 0 to 100%.\u003c/p\u003e","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7500806/v1/0f9bc5200eec150b40b61314.png"},{"id":91196161,"identity":"21c4f61a-dc9c-4d41-8eca-e5efc260afb3","added_by":"auto","created_at":"2025-09-12 15:01:38","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":2006856,"visible":true,"origin":"","legend":"\u003cp\u003eFigure illustrating the constant plantar fragment (\u003cstrong\u003e*\u003c/strong\u003e) and the plantar innominate ligament (\u003cstrong\u003eblack arrows\u003c/strong\u003e) on this plastinated anatomical specimen of a right foot.\u003c/p\u003e","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7500806/v1/a2a955d19477f8c7f509f5b3.png"},{"id":91197714,"identity":"b5fe916a-6383-4afc-96be-dfd2ba26c43d","added_by":"auto","created_at":"2025-09-12 15:09:38","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":3254058,"visible":true,"origin":"","legend":"\u003cp\u003eClinical case example\u003cstrong\u003e.\u003c/strong\u003e Imaging and 3D reconstruction of a Type 3 fracture (\u003cstrong\u003eA\u003c/strong\u003e). Intraoperative photograph. Initial reduction was incomplete at the level of the constant plantar fragment (white arrow with anchor marking)(\u003cstrong\u003eB\u003c/strong\u003e). Using a Weber clamp (yellow), the previously reduced body segment was realigned onto the plantar fragment, ensuring proper positioning of the entire body(\u003cstrong\u003eC\u003c/strong\u003e). Note the use of a distractor, which allowed for clear identification of the fragments and facilitated the reduction process.\u003c/p\u003e","description":"","filename":"figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-7500806/v1/4f51388024fe1a4d53c3637e.png"},{"id":91196168,"identity":"e24dbba6-46a7-4b60-b5b3-fd30920a8d8f","added_by":"auto","created_at":"2025-09-12 15:01:38","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":5207252,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative images, including stability testing after distractor removal (\u003cstrong\u003eA\u003c/strong\u003e). Postoperative X-ray and CT scan. Note the convergence of all screws toward the constant plantar fragment (\u003cstrong\u003eB\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-7500806/v1/bcf3609bf077de593fda143d.png"},{"id":91198885,"identity":"8f60fc76-d983-4378-aec6-ad8bbaf02b53","added_by":"auto","created_at":"2025-09-12 15:17:38","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":350945,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart\u003c/p\u003e","description":"","filename":"Flowchart.png","url":"https://assets-eu.researchsquare.com/files/rs-7500806/v1/1e79200935cffe2564e5033b.png"},{"id":93419760,"identity":"e10f37fb-2719-44a0-a312-5eb26edc14e5","added_by":"auto","created_at":"2025-10-13 16:07:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":15344666,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7500806/v1/c6662387-fd62-4179-9a59-0c1961923f0b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eNavicular Fracture Mapping: A New Perspective on Fracture Patterns and Surgical Strategies\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFractures of the tarsal navicular are uncommon, accounting for approximately 35.5% of midfoot injuries and 5% of all foot injuries.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Motor vehicle collisions (MVCs) are the most common cause, as a high-energy mechanism is typically required to generate the degree of impaction and distraction necessary to disrupt the navicular and adjacent structures. These forces often propagate along the medial column and may also affect the lateral column, leading to a high incidence of associated injuries. Evans et al. reported a 62% incidence of concomitant midfoot and hindfoot injuries on the same side.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThis susceptibility is due to the complex network of plantar and dorsal ligaments and the compact nature of the tarsal bones, which together confer significant structural rigidity to the midfoot. The interdependence between the medial and lateral columns of the foot has been likened to the pelvic ring, where injury to one side often implies compromise of the other.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe navicular bone plays a key role in hindfoot motion and gait. Anatomical reduction of this joint is critical for preserving mobility and preventing post-traumatic osteoarthritis. As the keystone of the medial longitudinal arch, the navicular contributes to maintaining the length and alignment of the medial column; shortening following fracture can result in hindfoot varus and forefoot abduction.\u003c/p\u003e\u003cp\u003eNavicular fractures are commonly classified into three types based on fracture pattern and joint involvement.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Type I and II fractures tend to preserve medial foot alignment, whereas Type III fractures are frequently associated with lateral comminution and displacement. This classification system has prognostic value for predicting the difficulty of reduction and potential clinical outcomes \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTalar-navicular fractures remain difficult to manage, particularly in polytrauma patients, due to their association with high-energy trauma and the resulting long-term morbidity.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Preoperative planning is essential, and understanding common fracture patterns is crucial to guide open reduction and internal fixation (ORIF). The presence of a constant plantar fragment, as described by Cronier et al., may serve as a reliable landmark for reduction in complex comminuted cases.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThree-dimensional (3D) reconstruction and fracture mapping techniques have already been validated in other anatomical regions, such as the calcaneus and acetabulum, to identify consistent fracture lines and constant fragments.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] However, such methodologies have not yet been systematically applied to navicular fractures.\u003c/p\u003e\u003cp\u003eThe aim of this study was to determine whether 3D fracture mapping of navicular fractures could identify constant fragments, as well as zones of impaction and comminution, to support improved reduction strategies and fixation, while preserving the delicate osseous and vascular anatomy of the navicular.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Patient Cohort\u003c/h2\u003e\u003cp\u003eThis was a single-center retrospective study conducted at a trauma center, following approval by the institutional review board. All patients presenting with an acute navicular fracture between 2007 and 2023 were included. Patient demographics including age, mechanism of injury, laterality, presence of an open fracture, and associated fractures of the foot and ankle were recorded.\u003c/p\u003e\u003cp\u003eExclusion criteria included age under 18 years and incomplete or non-assessable radiographic or CT data. All included CT scans encompassed the entire foot, from forefoot to hindfoot, with a maximum slice thickness of less than 3 mm. Scans were obtained pre- and postoperatively and accessed via the hospital\u0026rsquo;s Picture Archiving and Communication System (PACS). Fractures were classified according to the Sangeorzan classification.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCT Analysis and 3D Modeling\u003c/h3\u003e\n\u003cp\u003eRaw CT data were exported as DICOM (Digital Imaging and Communications in Medicine) files from PACS. Axial-plane data were imported into 3D Slicer (Brigham and Women\u0026rsquo;s Hospital; open-source software) to generate individual project files. Fractures were analyzed in axial, sagittal, and coronal planes simultaneously.\u003c/p\u003e\u003cp\u003eTo isolate the navicular bone and its fragments from surrounding tarsal structures, segmentation was performed using two templates: one for the navicular and another for adjacent bones. Articular surfaces and fragment boundaries were highlighted across at least three CT slices per anatomical plane. The segmented navicular was then converted into a 3D model and exported as an STL file for further analysis.\u003c/p\u003e\u003cp\u003e\u003cb\u003e3D Fracture Mapping\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFracture mapping methods followed standardized protocols described by Cole et al. and Xie et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Each STL file was imported into Blender (Blender Foundation; open-source software), where the main fragments were virtually reduced in three spatial dimensions. Fragment alignment was performed using anatomical landmarks, including the medial tuberosity, the inferior groove for the tibialis posterior tendon, the perforated dorsal cortex, and the lateral cuboid articular surface.\u003c/p\u003e\u003cp\u003eEach reconstructed fracture pattern was superimposed onto a template model of an uninjured navicular using a specific ICP (Iterative Closest Point) alignment add-on, based on the aforementioned landmarks. Left-sided fractures were mirrored to match the right side for standardization. Once proper anatomical alignment was confirmed (after a minimum of 50 iterations), fracture lines were manually traced as smooth curves on the template surface.\u003c/p\u003e\u003cp\u003eSuperimposing all individual fracture lines created a frequency-based fracture line map. In addition, zones of impaction and comminution were identified for each case, allowing the generation of corresponding 3D heat maps. These heat maps used a color gradient (from blue to red) to reflect the frequency of involvement. Impaction and comminution zones were analyzed according to four quadrants in a posteroanterior view: superomedial, superolateral, inferomedial, and inferolateral \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses were performed using R software (version 3.6.1; R Foundation for Statistical Computing). Qualitative variables were expressed as counts and percentages. Quantitative variables were presented as means with standard deviations (SD). Comparisons of quantitative variables were made using Student\u0026rsquo;s t-test, with statistical significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Confidence intervals were reported at the 95% level.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003ePatient characteristics\u003c/h2\u003e\u003cp\u003eA total of 54 navicular fractures were initially identified. Ten patients were excluded due to incomplete radiographic records. The final cohort consisted of 44 patients, of whom 36 (82%) were male and 8 (18%) were female, with a mean age of 34 years (range, 15\u0026ndash;74).\u003c/p\u003e\u003cp\u003eAccording to the Sangeorzan classification, 8 patients (18%) had Type I fractures, 10 (22%) had Type II fractures, and 26 (60%) had Type III fractures. Most injuries occurred during road traffic accidents (63.6%). Four patients (9.1%) had open fractures. One patient presented with a neurovascular injury that led to mid-term amputation.\u003c/p\u003e\u003cp\u003eAssociated injuries were common, found in 79.5% of cases, typically involving at least one of the three regions of the foot (forefoot, midfoot, or hindfoot). Patient demographics and fracture characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u0026ndash; Patient demographics and Fracture characteristics (N\u0026thinsp;=\u0026thinsp;44)*Only one case of a bilateral type 3 navicular fracture is represented here as 1 patient but in both sections into the laterality. **The values are given as the mean, with the range in parentheses.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTYPE 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTYPE 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTYPE 3\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSize (nbr. [%]*)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26 (60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (23\u0026ndash;74)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (15\u0026ndash;45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (16\u0026ndash;58)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (nbr. [%])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (90,0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 (85)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (10,0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLaterality (nbr. [%])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (52)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13 (48)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSkin coverage (nbr. [%])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (12)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClosed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (88)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConcomitant injuries (nbr. [%])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (19)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYES\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (81)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eForefoot\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMidfoot\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eHindfoot\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eOthers\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTreatments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" 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colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePlating\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eScrew\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eK-wire\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eother\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eFracture characteristics and management\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003eType I fractures\u003c/h2\u003e\u003cp\u003eType I fractures accounted for 18% of the cohort (n\u0026thinsp;=\u0026thinsp;8). These were simple transverse fractures without a consistent or reproducible pattern. No impaction or comminution zones were identified. Most cases were managed nonoperatively (5 patients, 62.5%). Surgical fixation was reserved for fractures with large or significantly displaced fragments.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eType II fractures\u003c/h3\u003e\n\u003cp\u003eType II fractures represented 22% of the cohort (n\u0026thinsp;=\u0026thinsp;10). Fracture lines followed an oblique dorsolateral-to-plantar-medial trajectory. Impaction zones were predominantly located along the lateral aspect of the talonavicular joint. Comminution was primarily concentrated in the superolateral quadrant of the navicular.\u003c/p\u003e\u003cp\u003eTreatment was tailored according to the degree of displacement and comminution. Surgical management was performed in 60% of cases, using screws or plates depending on fragment size and location.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eType III fractures\u003c/h2\u003e\u003cp\u003eType III fractures were the most common, representing 60% of the cohort (n\u0026thinsp;=\u0026thinsp;26). These injuries were frequently associated with additional midfoot (46%) or hindfoot (34%) fractures.\u003c/p\u003e\u003cp\u003eIn all Type III cases, a plantar region of the navicular remained intact, corresponding to what we termed the lateral plantar fragment. This constant fragment was present in 73% of Type III and 56% of Type II fractures.\u003c/p\u003e\u003cp\u003eImpaction zones consistently converged at the central portion of the talonavicular joint. Comminution was primarily located along the inferolateral aspect of the navicular and often extended toward the cuboideonavicular joint.\u003c/p\u003e\u003cp\u003eAn overview of these findings is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eUsing 3D fracture mapping techniques, we identified consistent fracture patterns in both Type II and Type III navicular fractures. These included recurrent zones of impaction and comminution, as well as the frequent presence of a constant plantar fragment.\u003c/p\u003e\u003cp\u003eType I fractures did not demonstrate any reproducible pattern. This may reflect true variability in morphology or could be due to the limited sample size in this subgroup.\u003c/p\u003e\u003cp\u003eIn Type II fractures, the predominant fracture line followed a sagittal trajectory from the dorsolateral to the plantar-medial corner, typically resulting in a large medial fragment. This finding reinforces the fracture pathway described in the Sangeorzan classification and supports currently established reduction and fixation strategies.\u003c/p\u003e\u003cp\u003eIn Type III fractures, analysis of all fracture lines revealed three primary fragments: a consistent plantar lateral fragment that remained uninvolved, a dorsolateral fragment, and a dorsomedial fragment. Cronier et al. attributed the preservation of the plantar fragment to the strength of the inferior calcaneonavicular (bifurcate) ligament, which anchors the fragment to the anterior process of the calcaneus.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] This pattern supports the designation of a \"constant fragment,\" analogous to the sustentaculum tali in calcaneal fractures. Rockett et al. also observed this fragment in CT-based analyses and incorporated it into their reduction strategy.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e3D mapping of impaction and comminution zones revealed consistent involvement of the dorsolateral quadrant. These areas varied in severity depending on fracture type, with more extensive damage observed in Type III fractures. This distribution appears to support the injury mechanism proposed by Rockett et al., particularly in Type III injuries, where axial loading of the talar head on a pronated hindfoot may exacerbate impaction and comminution.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe potential clinical value of 3D fracture mapping lies in its capacity to improve understanding of navicular fracture morphology, offering a reproducible framework for anticipating fragment configuration and zones of comminution. This is relevant because restoring talonavicular congruity and medial column length is critical for achieving favorable outcomes.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Despite applying these principles, secondary osteoarthritis remains common. In the series by Coulibaly et al., 85.4% of patients developed osteoarthritis following surgical treatment.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eFracture mapping may help surgeons anticipate the location of key fragments and tailor the surgical approach accordingly. This information may support decision-making around incision placement and exposure, with the aim of balancing adequate visualization with preservation of vascular integrity. Given the navicular\u0026rsquo;s limited blood supply, protecting its biological environment is essential to reduce the risk of avascular necrosis. DiGiovanni et al. emphasized the importance of an approach that permits simultaneous access to both the talonavicular and naviculo-cuneiform joints, while minimizing periosteal, capsular, or ligamentous stripping.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Respectful placement of plates and screws is also recommended to avoid devascularization.\u003c/p\u003e\u003cp\u003eSangeorzan et al. suggested that at least 60% of the talonavicular joint surface must remain intact to prevent postoperative subluxation.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] In our series, comminution was consistently located in the dorsolateral quadrant, an area often difficult to anatomically reduce, which may contribute to lateral subluxation of the talar head. Anatomical reduction of the less comminuted medial portion onto the plantar fragment, anchored to the calcaneal beak, may act as a stabilizing platform and help limit medial displacement of the navicular body. In our practice, the presence of a plantar fragment is taken into consideration during ORIF for Type III, and to some extent Type II fractures, as it may serve as a stable platform for repositioning the main navicular body. \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e A prospective clinical study would be required to determine whether this concept results in improved outcomes.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThis study has several limitations. It was retrospective and conducted at a single center. The use of the Sangeorzan classification, although widely adopted, may also be questioned, as it does not always capture medial border disruption or forefoot angulation. Schmid et al. have proposed an alternative classification based on the extent of talonavicular joint damage as visualized on preoperative CT scans, which may provide additional clinical relevance.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study illustrates the potential value of 3D fracture mapping in improving the understanding of navicular fracture morphology and injury mechanisms. By identifying consistent fracture patterns and key fragments, mapping may assist in refining surgical strategies. Optimizing reduction while preserving the bone\u0026rsquo;s biological integrity remains a central goal, in line with established AO principles.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding Statement\u003c/h2\u003e\u003cp\u003eThe authors declare that no funding was received for the conduct of this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eQDC : redacted the manuscriptVS : carried out data collectionCM : prepared figures and tableLR : carried out statistical analysesGD : proofread and corrected the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMarshall D, MacFarlane RJ, Molloy A, Mason L (2020) A review of the management and outcomes of tarsal navicular fracture. Foot Ankle Surg 26:480\u0026ndash;486. https://doi.org/10.1016/j.fas.2019.05.020\u003c/li\u003e\n \u003cli\u003eEvans J, Beingessner DM, Agel J, Benirschke SK (2011) Minifragment plate fixation of high-energy navicular body fractures. Foot Ankle Int 32:S485-492. https://doi.org/10.3113/fai.2011.0485\u003c/li\u003e\n \u003cli\u003eDiGiovanni CW (2004) Fractures of the navicular. Foot Ankle Clin 9:25\u0026ndash;63. https://doi.org/10.1016/S1083-7515(03)00173-6\u003c/li\u003e\n \u003cli\u003eSangeorzan BJ, Benirschke SK, Mosca V, et al (1989) Displaced intra-articular fractures of the tarsal navicular. J Bone Joint Surg Am 71:1504\u0026ndash;1510\u003c/li\u003e\n \u003cli\u003eRichter M, Thermann H, Wippermann B, et al (2001) Foot fractures in restrained front seat car occupants: a long-term study over twenty-three years. J Orthop Trauma 15:287\u0026ndash;293. https://doi.org/10.1097/00005131-200105000-00009\u003c/li\u003e\n \u003cli\u003eCronier P, Frin J-M, Steiger V, et al (2013) Internal fixation of complex fractures of the tarsal navicular with locking plates. A report of 10 cases. Orthop Traumatol Surg Res 99:S241\u0026ndash;S249. https://doi.org/10.1016/j.otsr.2013.03.001\u003c/li\u003e\n \u003cli\u003eCho J-W, Cho W-T, Sakong S, et al (2021) Mapping of acetabular posterior wall fractures using a three-dimensional virtual reconstruction software. Injury 52:1403\u0026ndash;1409. https://doi.org/10.1016/j.injury.2021.03.054\u003c/li\u003e\n \u003cli\u003eGuillaume D, Joshua A P, Remi DF, Cyril M (2024) Endopelvic Zones and Constant Fragment Mapping in Acetabular fractures. Injury 111652. https://doi.org/10.1016/j.injury.2024.111652\u003c/li\u003e\n \u003cli\u003eCole PA, Mehrle RK, Bhandari M, Zlowodzki M (2013) The Pilon Map: Fracture Lines and Comminution Zones in OTA/AO Type 43C3 Pilon Fractures. J Orthop Trauma 27:e152\u0026ndash;e156. https://doi.org/10.1097/BOT.0b013e318288a7e9\u003c/li\u003e\n \u003cli\u003eXie X, Zhan Y, Dong M, et al (2017) Two and Three-Dimensional CT Mapping of Hoffa Fractures. J Bone Jt Surg 99:1866\u0026ndash;1874. https://doi.org/10.2106/JBJS.17.00473\u003c/li\u003e\n \u003cli\u003eRockett MS, Brage ME (1997) Navicular body fractures: computerized tomography findings and mechanism of injury. J Foot Ankle Surg Off Publ Am Coll Foot Ankle Surg 36:185\u0026ndash;191. https://doi.org/10.1016/s1067-2516(97)80114-7\u003c/li\u003e\n \u003cli\u003eClements JR, Dijour F, Leong W (2018) Surgical Management Navicular and Cuboid Fractures. Clin Podiatr Med Surg 35:145\u0026ndash;159. https://doi.org/10.1016/j.cpm.2017.12.001\u003c/li\u003e\n \u003cli\u003eCoulibaly MO, Jones CB, Sietsema DL, Schildhauer TA (2015) Results and complications of operative and non-operative navicular fracture treatment. Injury 46:1669\u0026ndash;1677. https://doi.org/10.1016/j.injury.2015.04.033\u003c/li\u003e\n \u003cli\u003eSchmid T, Krause F, Gebel P, Weber M (2016) Operative Treatment of Acute Fractures of the Tarsal Navicular Body: Midterm Results With a New Classification. Foot Ankle Int 37:501\u0026ndash;507. https://doi.org/10.1177/1071100715624208\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejos","sideBox":"Learn more about [European Journal of Orthopaedic Surgery \u0026 Traumatology](http://link.springer.com/journal/590)","snPcode":"590","submissionUrl":"https://submission.springernature.com/new-submission/590/3","title":"European Journal of Orthopaedic Surgery \u0026 Traumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Fracture, midfoot, mapping, navicular, tarsal, 3D CT","lastPublishedDoi":"10.21203/rs.3.rs-7500806/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7500806/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Navicular fractures are rare and pose significant surgical challenges. This study aimed to define the location and frequency of fracture lines using both two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) mapping. We hypothesized that fracture mapping could reveal constant fragments, as well as patterns of impaction and comminution, to help optimize surgical management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective analysis of CT scans from 44 patients was performed. Fractures were classified according to the Sangeorzan system. Three-dimensional reconstructions were used to identify key fracture patterns, zones of impaction, and the presence of a constant plantar fragment, based on a 360-degree quadrant mapping approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Type I fractures (n = 8) were simple transverse fractures with no reproducible pattern. Type II fractures (n = 10) followed an oblique dorsolateral-to-plantar-medial trajectory, with 43% showing impaction in the lateral quadrant. Type III fractures (n = 26) were associated with comminution in 96% of cases and impaction in 81%, with fracture lines converging at the talonavicular joint. A constant plantar fragment was identified in 56% of Type II and 73% of Type III fractures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e 3D navicular fracture mapping may improve understanding of fracture morphology and injury mechanisms. By identifying consistent fracture features, this technique may assist in preoperative planning and inform reduction and fixation strategies.\u003c/p\u003e\n\u003cp\u003eLevel of evidence : IV\u003c/p\u003e","manuscriptTitle":"Navicular Fracture Mapping: A New Perspective on Fracture Patterns and Surgical Strategies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-12 15:01:33","doi":"10.21203/rs.3.rs-7500806/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-09-27T18:13:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-21T20:12:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248716861005470278028412651182028093571","date":"2025-09-12T00:01:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-06T23:18:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-01T06:22:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-01T06:20:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Orthopaedic Surgery \u0026 Traumatology","date":"2025-08-31T13:12:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejos","sideBox":"Learn more about [European Journal of Orthopaedic Surgery \u0026 Traumatology](http://link.springer.com/journal/590)","snPcode":"590","submissionUrl":"https://submission.springernature.com/new-submission/590/3","title":"European Journal of Orthopaedic Surgery \u0026 Traumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d44e95bd-799a-4f54-bb71-fe0ec62e3b75","owner":[],"postedDate":"September 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:02:17+00:00","versionOfRecord":{"articleIdentity":"rs-7500806","link":"https://doi.org/10.1007/s00590-025-04550-8","journal":{"identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isVorOnly":false,"title":"European Journal of Orthopaedic Surgery \u0026 Traumatology"},"publishedOn":"2025-10-07 15:57:14","publishedOnDateReadable":"October 7th, 2025"},"versionCreatedAt":"2025-09-12 15:01:33","video":"","vorDoi":"10.1007/s00590-025-04550-8","vorDoiUrl":"https://doi.org/10.1007/s00590-025-04550-8","workflowStages":[]},"version":"v1","identity":"rs-7500806","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7500806","identity":"rs-7500806","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}