Madelung's Deformity

Original Editor - Shwe Shwe U Marma Top Contributors - Shwe Shwe U Marma

Introduction

Madelung’s deformity is a condition of the wrist characterized by a shortened distal radius with volar–ulnar curvature and a dorsally prominent distal ulna.[1]

Madelung's deformity

A Vickers’ ligament is the feature to differentiate Madelung’s deformity from Madelung-like deformities.[2]

Epidemiology

Predominantly adolescent females are affected by a ratio of 4:1. The deformity is bilateral most often.[3]

Clinical Features

  • Initially asymptomatic, progressive clinical deformity
  • Pain at wrist
  • Loss of wrist extension
  • Compromised forearm rotation
  • “Bayonet” deformity- prominent distal ulna as a result of dorsal subluxation[4]
  • Girls are more often affected than boys
  • Presents between the ages of 6 and 13 years[5]

Pathogenesis

Premature growth plate arrest at the medial volar aspect of the distal radius causes Madelung deformity. Repetitive traumatic pressure may result in Madelung-like deformity. Mutation or absence of the short stature homeobox (SHOX) gene is thought to be the cause of congenital Madelung deformity.

Congenital Madelung deformity can occur as a part of Leri-Weill dyschondrosteosis (LWD) or Turner syndrome.[6]

Diagnosis

Key Features from X-Ray

  • increased dorsal and radial convexity of the distal radius
  • increased volar and ulnar tilt of the distal radial articular surface
  • widened interosseous space
  • relative dorsal position of the ulnar head
  • pyramiding of the carpus[3]

MRI

MRI is done on the patients who need the surgical release of Vickers’ ligament to prevent deformity progression.[5]

Differential Diagnosis

  • Turner syndrome
  • Nail-patella syndrome
  • Hereditary, multiple exostoses
  • Ollier’s disease
  • Achondroplasia
  • Multiple epiphyseal dysplasias
  • Mucopolysaccharidoses (Hurler and Morquio syndrome)[7]

Treatment

Conservative Management

Conservative management of Madelung’s deformity may be helpful for skeletally mature patients with the following measures:

  • Physiotherapy
    • to reduce pain
      • Icing
      • Cold whirlpool immersion
      • Transcutaneous electrical nerve stimulation
    • limited pronation and supination suggests the need of exercise to help maintaining and/or increasing the power of involved muscles, i.e.- pronators and supinators[8]
  • oral analgesics
  • activity restriction
  • volar splint[9]

Surgical Management

  • Radial or ulnar osteotomy
  • Vickers’ ligament resection
  • Ulnar epiphysiodesis[10]

References

  1. Dubey A, Fajardo M, Green S, Lee SK. Madelung’s deformity: a review. Journal of Hand Surgery (European Volume). 2010 Mar;35(3):174-81.
  2. Prasad N, Venkatesh M. Madelung Deformity of the Wrist: A Classic Presentation. International Journal of Contemporary Medicine Surgery and Radiology. 2020;5:C4-5
  3. 3.0 3.1 Thomson C, Hawkes D, Nixon M. Madelung’s Deformity: Diagnosis, Classification and Treatment. Journal of Orthoplastic Surgery. 2020 Apr 17;4(1):1-1.
  4. Babu S, Turner J, Seewoonarain S, Chougule S. Madelung's Deformity of the Wrist—Current Concepts and Future Directions. Journal of wrist surgery. 2019 Jun;8(03):176-9.
  5. 5.0 5.1 Knutsen EJ, Goldfarb CA. Madelung's deformity. Hand. 2014 Sep;9(3):289-91.
  6. Tranmer A, Laub Jr D. Madelung deformity. Eplasty. 2016;16.
  7. Kakarla S. Madelung and pseudo Madelung deformities-Pictorial essay. Journal of Medical and Scientific Research. 2019;7:1-6
  8. Brooks TJ. Madelung deformity in a collegiate gymnast: a case report. Journal of Athletic Training. 2001 Apr;36(2):170.
  9. Shahi P, Sudan A, Sehgal A, Meher D, Meena U. Madelung Deformity of the Wrist Managed Conservatively. Cureus. 2020 May;12(5).
  10. Bebing M, de Courtivron B, Pannier S, Journeau P, Fitoussi F, Morin C, Violas P. Madelung's deformity in children: Clinical and radiological results from a French national multicentre retrospective study. Orthopaedics & Traumatology: Surgery & Research. 2020 Nov 1;106(7):1339-43.