A 62-year-old woman with a history of severe seizure disorder was found down in an awkward position by her husband, reportedly with brief loss of consciousness at the scene. She was brought into the emergency department by her husband the following day, with altered mental status and complaints of right ankle and foot pain. Due to her post-ictal state, she was unable to provide further details regarding the mechanism of injury.
Initial imaging included computed tomography (CT) of the head and cervical spine, which showed no acute abnormalities, and CT of the chest, which showed changes consistent with acute aspiration pneumonia. Radiographs of her right foot and ankle showed acute fractures of the navicular and calcaneus (Fig. 1). Because the fracture pattern on radiographs suggested a high-energy injury to the midfoot and forefoot, a lower extremity CT was performed to detect any occult injuries and to further characterize the known fractures (Fig. 2). The CT demonstrated a comminuted fracture of the anterolateral aspect of the calcaneus with extension into the calcaneocuboid joint, an avulsion fracture of the navicular tuberosity, a mildly displaced fracture of the inferior aspect of the lateral cuneiform, and a minimally displaced fracture of the anterolateral corner of the distal tibia.
Within a few hours after admission, the patient required endotracheal intubation for respiratory support. She was evaluated by orthopaedics, and a closed reduction was attempted and her right foot splinted in anticipation of early elective open reduction and internal fixation of the fractures of her right foot. Ultimately, however, she was unable to undergo surgery due to severe aspiration pneumonia necessitating ventilatory support for several weeks. Because of this crucial delay, the decision was made to immobilize her foot in a non-weightbearing cast and treat her non-operatively with regular follow-up in orthopaedic clinic. Follow-up radiographs obtained three months after the injury showed non-union of the navicular fracture with fragmentation, and persistent shortening of the lateral column (Fig. 3).