Background. The only existing classification of Müller-Weiss Disease (MWD), based solely on Méary's angle, serves neither as guide for prognosis nor treatment. This accounts for lack of gold standard in its management. Methods. Navicular compression, medial extrusion, Kite's angle and metatarsal lengths were measured on all radiographs of 95 feet with MWD. Joints involved, presence and location of navicular fracture were recorded. Results. We identified three distinct groups. Group 1 comprises 11 “early-onset” MWD feet, aged 9 to 29 years. These had the greatest compression and medial extrusion, and lowest Kite's angles. All except 1 were index minus and had a lateral navicular fracture. None has required surgery to date. Only 1 has moderate talonavicular joint (TNJ) degeneration. Group 2 comprises 23 “Müller-Weissoid” feet with radiologically normal navicular in their fifties and developing MWD, on average, 4.5 years later. These had the lowest compression and extrusion, and highest Kite's angles. None had complete fracture. All had TNJ arthritis, with early changes at lateral naviculocuneiform joint (NCJ) in 43%. Group 3 “late-onset” MWD, presenting in the sixth decade, is subdivided into 3 sub-groups. Only TNJ is involved in group 3A (16). Group 3B denotes affection of TNJ more than NCJ (20). In group 3C “reverse Müller-Weiss disease”, which affects NCJ more than TNJ (25), second metatarsal overlength is highest of all groups. No difference in age, compression, extrusion and Kite's angle exists among the 3 subgroups. No fracture occurred in group 3A compared to 65% and 32% in groups 3B and 3C, respectively. Conclusions. With a need to compare like-for-like pathology, the proposed classification provides a common platform for reporting outcomes of different treatment modalities, operative or nonoperative. We theorize pathogenetic pathways in the different groups and propose systematic surgical approaches for each category

We present a case of a 14 year old who sustained an isolated injury to her foot while horse riding. X-rays demonstrated a medial and plantar dislocation at the level of the talo-navicular and calcaneo-cuboid joint, with associated fractures of the cuboid and navicular. This was treated initially with open reduction and fixation with kirschner wires as the injury was grossly unstable and reduction difficult to maintain with casting alone. CT scan was then performed prior which confirmed satisfactory reduction of the dislocation and fixation with the k wires so these were left in situ and the navicular fracture reduced and fixed with a barouk screw. The Chopart joint was first described by French surgeon Francois Chopart as the talo-navicular and calcaneo-cuboid joints were a practical level for amputation. Injury here is a rare but missed in 40% at presentation. Pure dislocation occurs in 10–25% with most having concomitant fractures. The Chopart joint has critical role in balance and stability in normal gait. Early recognition allows prompt reduction and fixation of these injuries which has been associated with a better outcome. However these are severe injuries and patients should be counselled on potential long term functional impairment even with optimal management

Introduction The purpose of this paper is to describe our management of complex fractures of the distal radius and ulna using a combined type of stabilization, external with a Pennig fixator, internal with radial augmentation with plate. The patient have substained a several general trauma or an high energy scheletral trauma upper limbs. Treatment In a period from 24 july 2002 to today 8 october 2004 (26 months) we have treated surgically 93 wrists with distal radial fractures in 85 patient. 4 patients bilaterally, 3 patients have substained a secondary reprease for lacking the initial reduction and 2 in two programmed timing. 46 wrists with radial internal fixation single or double plate (in one case trhee plate). 12 plate with pin or single screw in augmentation. 3 cases with only screw artroscopically assisted. 14 cases with only external fixator with or without pin. 18 wrist with a combination of radial internal fixation (plate) and external fixation with Pennig, in complex distal radial-ulna fracture (2 exposed). In 5 wrists there were associated and treated navicular fracture or intracarpal ligaments injury. 1 pazient have sustained an ipsilateral forearm fracture, epiphiseal distal radial fracture, trans scapho-lunate dislocation and controlateral transcapho-lunate dislocation. 1 patient have sustained ipsilateral navicular-fisrt metacarpal-radial and ulna fracture. The most patients (...) have been treated from the first Author. The patients were controlled from minimum of 6 month up a maximum of 39 months. We have adapted in our evaluation the Dash score system. The main problem, in the follow up results is a lack of prono-supination that stresses the importance of a perfect reduction of distal radio-ulnar joint to begin early a phisiotherapy. Clinical results In conclusion our experince in timing of treatment indicate that is important fixate the lesions earlier, whenever the priority of treatment on severly injured pazients are respected. We believe that a combination of the two fixation system allow an optimal external stabilization in the first week (So the terapist can move the patients in intensive care room). Secondary the internal fixator allows an anatomical reduction with a stable fixation in the secondary kinesiterapeutic time protocol of high energy trauma to distal forearm, in particular in politraumatized patients is:. - closed reduction and short cast or external fixator if exposed or severe instable, on the day of injury during or just following generally stabilization. - if possible e Tc 3D dimensional scan (our patients have substained a lot of tc scan for other trauma). - internal reduction and stabilitation a fews days later when the local swelling or skin damage and general condition allow it (from 2 to 7). - removal of external fixator between 3–4 week and begin a complete fkt

To evaluate the mechanism of dislocation of the navicular in complex foot trauma; we hypothesize this is similar to lunate/perilunate dislocations. Our experience with 6 cases of total dislocation of navicular without fracture, and an analysis of 7 similar cases reported world-wide was used as the basis for this hypothesis. Radiographs of our patients and the published cases were analyzed in detail, and associated injuries/instablilities were assessed. The position of the dislocated navicular and the mechanism of trauma was considered and correlated, and this hypothesis was propounded. When the navicular dislocates without fracture, it most frequently comes to lie medially, with superior or inferior displacement, depending upon the foot position at injury. It is hypothesized that the forefoot first dislocates laterally (perhaps transiently) at the naviculocunieform joint by an abduction injury; in all cases we recorded significant lateral injury (either cuboid fracture, or lateral midfoot dislocation). The relocating forefoot subsequently pushes the unstable navicular from the talonavicular joint, and depending upon the residual attachments of soft tissues, this bone comes to lie at different places medially. This is a similar mechanism to the lunate dislocation in the wrist, where the relocating carpus push the lunate volarly. Our clinical experience with these complex injuries has shown that the whole foot is extremely unstable. For reduction, the talonavicular joint has to be reduced first, and then the rest of the forefoot easily reduces on to the navicular. An understanding of injury mechanics allows us to primarily stabilize both the columns of the foot, and subsequent subluxation and associated residual pain are avoided. Pure navicular dislocations are not isolated injuries, but are complex midfoot instabilities, and are similar to perilunate injuries of the wrist