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Ma Y, Guo Z, Wang L, Wang Q, Cheng X, Yan D. Assessment of 3.0 Tesla magnetic resonance imaging in Madelung's deformity: findings and implications. BMC Musculoskelet Disord 2024; 25:133. [PMID: 38347477 PMCID: PMC10860302 DOI: 10.1186/s12891-024-07245-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 01/30/2024] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE The aim of the study was to investigate the 3.0 Tesla magnetic resonance imaging (MRI) features of Madelung's deformity. MATERIALS AND METHODS The wrist MRI scans of 19 patients clinically diagnosed with Madelung's deformity and 20 patients without deformity were consecutively selected from Beijing Jishuitan Hospital between April 2019 and December 2022 for observation, in the case group and control group, respectively. Multiple linear regression was used to analyze the factors affecting tilting angle and width of central disc (CD, also termed as triangular fibrocartilage, the main component of triangular fibrocartilage complex), while the chi-square test was used to compare the occurrences of CD (radial) attachment displacement, VL, and RTL. p < 0.05 indicated statistical significance. RESULTS Madelung's deformity significantly contributed to the tilting and thickening of the CD. In the case group, the tilting angle and thickness of CD were (51.46 ± 1.33)° and (0.23 ± 0.01) cm, respectively, which was statistically significant (p < 0.05); the radial attachment of the CD significantly shifted away from the distal articular surface level (χ2 = 39.00, p < 0.001), with a mean displacement of (0.97 ± 0.38) cm. Furthermore, the cases demonstrated abnormally developed Vickers ligament (χ2 = 35.19, p < 0.001) and radiotriquetral ligament (χ2 = 25.66, p < 0.001). CONCLUSION MRI provides a notable advantage in diagnosing Madelung's deformity. Compared with the control group, patients with Madelung's deformity exhibited tilting and thickening of the CD. Additionally, the radial attachment of the CD was significantly shifted proximally with abnormal development of Vickers and radiotriquetral ligaments.
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Affiliation(s)
- Yimin Ma
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Zhe Guo
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Ling Wang
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Qianqian Wang
- Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Xiaoguang Cheng
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Dong Yan
- Department of Radiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China.
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Farr S, Zlotolow DA, Bachy M, Peymani A, Hülsemann W, Winge MI. State of the art review: The pathogenesis and management of Madelung deformity. J Hand Surg Eur Vol 2023; 48:1116-1125. [PMID: 37572317 DOI: 10.1177/17531934231191208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
Madelung deformity remains a fascinating yet unresolved challenge. There is an increasing awareness for early diagnosis by healthcare providers with improvement in diagnostic modalities, however, the exact mechanisms for the development of the deformity have still to be clarified. While some corrective procedures have been described to effectively address an established deformity, the existing literature lacks clear and evidence-based treatment guidelines on how to proceed in daily practice. This review article aims to summarize the current best evidence on this topic, including particular areas of controversy and areas with need for future research.
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Affiliation(s)
- Sebastian Farr
- Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopaedic Hospital Speising, Vienna, Austria
| | - Dan A Zlotolow
- Shriners Hospitals for Children, Philadelphia and Greenville; The Hospital for Special Surgery, New York, USA
| | - Manon Bachy
- Sorbonne University, AP-HP, Hôpital Trousseau, Service de Chirurgie Orthopédique et réparatrice de l'enfant, Paris, France
| | - Abbas Peymani
- Amsterdam UMC, Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam, The Netherlands
| | - Wiebke Hülsemann
- Handsurgery Department, Children's Hospital Wilhelmstift, Hamburg, Germany
| | - Mona I Winge
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
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Oliveira RKD, Ribak S, Brunelli JPF, Aita M, Delgado PJ. Madelung Deformity: Diagnosis and Treatment Options. REVISTA IBEROAMERICANA DE CIRUGÍA DE LA MANO 2021. [DOI: 10.1055/s-0041-1739452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractMadelung deformity (MD) comprises an increased volar and ulnar tilt of the joint facet of the distal radius, secondary to an idiopathic physeal dysplasia. Such change causes radial shortening and consequent distal ulnar prominence, along with wrist pain and loss of motion. Surgery becomes an option in patients with severe deformity that do not respond to conservative treatment.The classic surgical techniques are problematic for adults, as they are specific for children and adolescents, whose radial physis is still open. Very few papers discuss the treatment of adult patients; furthermore, most are focused on the distal radioulnar joint, and thus do not approach the origin of the pathology.When analyzing computed tomography scans with tridimensional reconstruction, a feature of MD, growth arrest of the volar and ulnar portions of the distal radius, is noted, causing the typical distal radius deformity that leads to lack of coverage of the lunate bone. That leads to palmar subluxation of the lunate bone and consequent radiocarpal instability.We herein describe the possibilities of treatment in different stages of evolution, summarizing the authors' view on MD.
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Affiliation(s)
| | - Samuel Ribak
- Department of Hand Surgery, Pontifícia Universidade Católica de Campinas, Campinas, Brazil
| | | | - Márcio Aita
- Department of Hand Surgery, Faculdade de Medicina do ABC, Santo André, Brazil
| | - Pedro J. Delgado
- Department of Hand and Upper Limb Surgery, Hospital Universitário HM Montepríncipe, Universidad CEU San Pablo, Boadilla del Monte, Madrid, Spain
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Peymani A, de Roo MGA, Dobbe JGG, Streekstra GJ, McCarroll HR, Strackee SD. Carpal Kinematics in Madelung Deformity. J Hand Surg Am 2021; 46:622.e1-622.e12. [PMID: 33849749 DOI: 10.1016/j.jhsa.2020.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 10/03/2020] [Accepted: 11/20/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Various skeletal and soft tissue abnormalities have been identified in Madelung deformity and have been hypothesized to play a causal role in its progressive symptomatology; however, our pathological understanding of these changes remains limited. In this study, we biomechanically assessed the Madelung deformity wrist, using 4-dimensional computed tomography imaging. METHODS Nine Madelung deformity wrists (5 patients; age, 24 ± 5 y) and 18 healthy wrists (9 volunteers; age, 28 ± 3 y) underwent 4-dimensional imaging during flexion-extension motion and radioulnar deviation. Carpal kinematics and radiocarpal joint parameters were quantified and compared. RESULTS In Madelung deformity wrists, significantly decreased rotation was seen in the lunate (-4.6°) and the triquetrum (-4.8°) during flexion-extension motion. During radioulnar deviation, significant decreases were visible in lunate bone translation (-0.7 mm), triquetrum bone translation (-0.6 mm), and triquetrum bone rotation (-1.9°). Patients had significantly decreased articulating surface areas of the scaphoid (1.4 ± 0.2 cm2 versus 1.6 ± 0.2 cm2) and lunate (1.2 ± 0.4 cm2 versus 1.5 ± 0.3 cm2) fossa, and significantly increased radioscaphoid (1.3 ± 0.1 mm versus 1.2 ± 0.1 mm) and radiolunate (1.6 ± 0.2 mm versus 1.3 ± 0.3 mm) joint space thicknesses. CONCLUSIONS There is a decreased mobility of the lunate and triquetrum bones in Madelung deformity. CLINICAL RELEVANCE Four-dimensional imaging could be used in future studies that investigate the effect of surgical ligament release on carpal kinematics and subsequent wrist mobility.
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Affiliation(s)
- Abbas Peymani
- Department of Plastic, Reconstructive and Hand Surgery; Department of Biomedical Engineering and Physics.
| | - Marieke G A de Roo
- Department of Plastic, Reconstructive and Hand Surgery; Department of Biomedical Engineering and Physics
| | | | - Geert J Streekstra
- Department of Biomedical Engineering and Physics; Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henry R McCarroll
- Department of Orthopaedic Surgery, California Pacific Medical Center, San Francisco, CA
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De Leucio A, Castelein S, Bellemans M, Simoni P. Radiotriquetral Ligament in Madelung's Deformity Associated with Leri-Weill's Dyschondrosteosis. Cureus 2020; 12:e7100. [PMID: 32231895 PMCID: PMC7098412 DOI: 10.7759/cureus.7100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Madelung's deformity (MD) is frequently associated with Leri-Weill's dyschondrosteosis (LWD) even if the primary isolated form (PI-MD) is much more common. Recent studies pointed out how two abnormal ligaments, the Vickers ligament (VL) and the radiotriquetral ligament (RTL), are defining traits of MD. To date, in PI-MD, both VL and RTL have been reported. In MD associated with LWD (LWD-MD), the VL is also present, but the RTL has never been reported. We herein report the first case of MD associated with a genetically confirmed LDW with an RTL, detected on MRI. This report describes the MRI imaging features of MD-LWD, which have not been adequately characterized in previous literature.
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Affiliation(s)
- Alessandro De Leucio
- Radiology and Medical Imaging, Queen Fabiola Children's University Hospital, Brussels, BEL
| | - Sybille Castelein
- Orthopedics and Traumatology, Queen Fabiola Children's University Hospital, Brussels, BEL
| | - Michel Bellemans
- Orthopedics and Traumatology, Queen Fabiola Children's University Hospital, Brussels, BEL
| | - Paolo Simoni
- Radiology and Medical Imaging, Queen Fabiola Children's University Hospital, Brussels, BEL
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Peymani A, Dobbe JGG, Streekstra GJ, McCarroll HR, Strackee SD. Quantitative three-dimensional assessment of Madelung deformity. J Hand Surg Eur Vol 2019; 44:1041-1048. [PMID: 31550979 PMCID: PMC6838729 DOI: 10.1177/1753193419876203] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In the diagnostic work-up of Madelung deformity conventional radiographic imaging is often used, assessing the three-dimensional deformity in a two-dimensional manner. A three-dimensional approach could expand our understanding of Madelung deformity's complex wrist anatomy, while removing inter- and intra-rater differences. We measured previous two-dimensional-based and newly developed three-dimensional-based parameters in 18 patients with Madelung deformity (28 wrists) and 35 healthy participants (56 wrists). Madelung deformity wrists have increased levels of ulnar tilt, lunate subsidence, lunate fossa angle, and palmar carpal displacement. The lunate fossa is more concave and irregular, and angles between scaphoid, lunate, and triquetral bones are decreased. These findings validate the underlying principles of current two-dimensional criteria and reveal previously unknown anatomical abnormalities by utilizing novel three-dimensional parameters to quantify the radiocarpal joint.
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Affiliation(s)
- Abbas Peymani
- Department of Plastic, Reconstructive and Hand Surgery, University of Amsterdam, Amsterdam, Netherlands,Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, Netherlands,Abbas Peymani, Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Johannes G. G. Dobbe
- Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, Netherlands
| | - Geert J. Streekstra
- Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, Netherlands,Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, Netherlands
| | - Henry R. McCarroll
- Department of Orthopaedic Surgery, California Pacific Medical Center, San Francisco, CA, USA
| | - Simon D. Strackee
- Department of Plastic, Reconstructive and Hand Surgery, University of Amsterdam, Amsterdam, Netherlands
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7
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Peymani A, Johnson AR, Dowlatshahi AS, Dobbe JGG, Lin SJ, Upton J, Streekstra GJ, Strackee SD. Surgical Management of Madelung Deformity: A Systematic Review. Hand (N Y) 2019; 14:725-734. [PMID: 30102073 PMCID: PMC6859600 DOI: 10.1177/1558944718793179] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Madelung deformity is a congenital wrist condition characterized by volar subluxation of the wrist caused by premature growth arrest of the distal radius. Progressive symptoms can necessitate surgical intervention, yet optimal treatment strategy remains unknown. The aim of this study is to determine treatment options, surgical indications, and operative outcomes for Madelung deformity. Methods: This study adhered to the Meta-Analyses of Observational Studies in Epidemiology (MOOSE) guidelines. A comprehensive systematic review was performed to identify all studies describing surgical interventions for Madelung deformity. All studies were evaluated by level of evidence and a self-developed quality assessment tool. Results: Twenty-five studies met inclusion criteria; all case series with type IV level of evidence. Studies assessed pain, range of motion, aesthetic deformity, and grip strength. The primary indication for surgery was the presence of wrist pain. Various surgical procedures exist and could be categorized as radial lengthening, ulnar shortening, or a combination of both. All studies report postoperative pain reduction and most studies report an improved range of motion. Conclusions: A variety of surgical procedures reportedly have satisfactory outcomes. However, outcomes are reported in an inconsistent manner, prohibiting pooling of studies and comparisons of surgical procedures and their outcomes. We propose several methodological changes for implementation in future studies, increasing the quality of evidence to compensate for small patient numbers.
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Affiliation(s)
- Abbas Peymani
- University of Amsterdam, The
Netherlands,Harvard Medical School, Boston, MA,
USA,Abbas Peymani, Department of Plastic,
Reconstructive and Hand Surgery, Academic Medical Center, University of
Amsterdam, Room G4-226, Meibergdreef 9, PO Box 22660, 1100 DD Amsterdam, The
Netherlands.
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Créteur V, Madani A, Bianchi S. Sonographic Findings in Adult Congenital Madelung Deformity: A Case Study. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2019. [DOI: 10.1177/8756479319872151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This case study describes six sonographic findings, with correlative imaging, in an adult patient with congenital Madelung deformity. Two are typical of congenital Madelung deformity: a thick volar hyperechoic band extending from the ulnar side of the distal radius toward the lunate-triquetrum area, the so-called Vickers ligament, adjacent to the radiotriquetral ligament, and a cortical defect on the ulnar and volar side of the distal radius. Other findings may be also observed, such as a narrowed distance between the Lister tubercle and the distal radioulnar joint, a dorsal subluxation of the ulnar head, an extensor tendons entrapment and pronator quadratus modifications. Although the diagnosis of congenital Madelung deformity is based usually on clinical examination, this rare malformation may remain undiscovered until adulthood. When sonography is used as the first imaging technique, the sonographic findings of congenital Madelung deformity can facilitate diagnosis and the appropriate radiographs.
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Affiliation(s)
- Viviane Créteur
- Department of Radiology Hospital Erasme—ULB University Clinic of Brussels, Brussels Belgium
| | - Afarine Madani
- Department of Radiology Hospital Erasme—ULB University Clinic of Brussels, Brussels Belgium
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MRI appearance of the anomalous volar radiotriquetral ligament in true Madelung deformity. Skeletal Radiol 2019; 48:915-918. [PMID: 30341713 DOI: 10.1007/s00256-018-3094-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/24/2018] [Accepted: 10/04/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To characterize the MRI appearance of the anomalous volar radiotriquetral ligament in cases of classic Madelung deformity. MATERIALS AND METHODS With institutional review board approval, a search of the radiology information system was performed to identify cases of potential Madelung deformity using variations of the criteria "Madelung deformity." Cases of classic Madelung deformity were included based on the following criteria: dorsal subluxation of the ulnar head, volar tilt of the distal radius, increased radial inclination of greater than 25°, triangulation of the carpus, and presence of Vickers ligament defined as an anomalous volar radiolunate ligament. Patients with a history of wrist trauma or severe degenerative change distorting anatomy were excluded. The resulting cases were reviewed to characterize the anomalous radiotriquetral ligament. RESULTS Eight cases of classic Madelung deformity in 6 patients were identified. All 8 cases were characterized by the presence of an anomalous radiotriquetral ligament, which was more conspicuous than Vickers ligament. None of the excluded pseudo-Madelung deformity cases displayed a Vickers ligament or radiotriquetral ligament. CONCLUSION The radiotriquetral ligament is an anomalous ligament that is a constant and distinguishing finding in classic Madelung deformity in this study. Awareness of the radiotriquetral ligament and distinguishing it from Vickers ligament on imaging studies and at surgery may have clinical implications that need to be further investigated.
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Hegazy G, Mansour T, Alshal E, Abdelaziz M, Alnahas M, El-Sebaey I. Madelung's deformity: capitate-related versus ulna-related measurement methods. J Hand Surg Eur Vol 2019; 44:524-531. [PMID: 30813847 DOI: 10.1177/1753193419832233] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Several investigators have defined measurements for Madelung's deformity based on the distal radius or on the longitudinal ulnar axis to avoid the distorted distal radius and its lunate fossa. However, errors may occur in severe cases because of ulnar deformity and displacement. We quantified seven established measurements for Madelung's deformity relying on the central axis of the capitate. The inter- and intrarater reliability of the capitate-related and the ulna-related techniques were compared. We observed a higher inter- and intrarater reliability for the capitate-related method than for the ulna-related method. Better agreement was also observed for measurements of distance than for measurements of angles. However, the palmar tilt angle measurement method was neither reliable nor reproducible. The capitate-related technique can help to accurately determine the severity of Madelung's deformity, assist in surgical planning and identify the prognosis. Level of evidence: III.
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Affiliation(s)
- Galal Hegazy
- 1 Orthopedic Department, AL-Azhar University, Cairo, Egypt
| | - Tarek Mansour
- 2 Radio-diagnosis Department, AL-Azhar University, Assiut, Egypt
| | - Ehab Alshal
- 3 Orthopedic Department, AL-Azhar University, Assiut, Egypt
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11
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Treatment of Madelung Deformity With Vicker Ligament Release and Radial Physiolyses: A Case Series. J Hand Surg Am 2019; 44:158.e1-158.e9. [PMID: 29934079 DOI: 10.1016/j.jhsa.2018.04.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 03/28/2018] [Accepted: 04/28/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the surgical outcomes in a series of Madelung wrists treated with a Vicker ligament release at a young age. We hypothesize that early treatment of Madelung deformity with Vicker ligament release is safe and may minimize progression of deformity. METHODS A retrospective review was performed at a single large pediatric institution from 2013 to 2016 of patients with a diagnosis of Madelung deformity treated with Vicker ligament release and radial physiolysis. Exclusion criteria included patients who were skeletally mature, who underwent osteotomy procedures, or who had incomplete follow-up. Patient demographics were collected, concomitant surgeries were recorded, and outcomes including range of motion and pain were documented. Measurements of standard anteroposterior and lateral radiographs were calculated before and after surgery to monitor radiographic deformity and progression. RESULTS Six girls with bilateral Madelung deformity who underwent bilateral Vicker ligament resection and radial physiolysis (12 total wrists) were included. The average age at presentation was 7.5 years (range, 7-9 years), with an average follow-up of 30 months. Reasons for presentation included sports injuries (2), ulnar-sided wrist pain (2), and mild deformity (2). Additional radial and ulnar epiphysiodeses were performed in 2 wrists each. There were no intraoperative complications. Although pain resolved within the first month after surgery for all patients, 2 patients had intermittent unilateral ulnar-sided wrist pain at final follow-up. All patients returned to their presurgery activities. There was no loss of range of motion, and 4 wrists with preoperative supination deficits improved by an average of 17°. Radiographic measurements demonstrated improvement in the radial physeal angle in 10 out of 12 wrists (83%). No patients displayed worsening deformity after surgery. Two patients underwent subsequent procedures. CONCLUSIONS In patients with early Madelung deformity, Vicker ligament release with radial physiolysis is a safe treatment option that theoretically has the potential to minimize the progression of radiographic deformity. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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12
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Kwon SW, Hong SJ, Nho JH, Moon SI, Jung KJ. Physeal fracture in the wrist and hand due to stress injury in a child climber: A case report. Medicine (Baltimore) 2018; 97:e11571. [PMID: 30142752 PMCID: PMC6112917 DOI: 10.1097/md.0000000000011571] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE In competitive athletes, the upper extremity is subject to tremendous torsional forces with axial loading due to repetitive weight bearing. Approximately 25% of injuries in sports are related to the hand or wrist. Skeletal deformity on the wrist physis is common in athletes due to repetitive loading and presents at early ages between 6 and 13 years. Additionally, it is more common in female than in male athletes. PATIENT CONCERNS An 11-year-old girl who was a climber complained of pain on her left wrist without direct trauma. She had participated in climbing exercise for several years and had no medical history. Thorough radiological evaluation, we diagnosed physeal injury of the left radius. After healing of the physeal injury of the radius, she complained of pain on fourth finger of right hand and radiographs revealed physeal injury of the right fourth finger. DIAGNOSIS Radiographs revealed physeal injury of the left radius. Magnetic resonance imaging revealed epiphyseal widening of the radial aspect of the wrist and bone marrow signal increase on T2-weighted imaging. Likewise, radiographs showed physeal injury of the right fourth finger INTERVENTIONS:: No surgery was performed and we applied wrist brace and finger splint for conservative treatment. OUTCOMES The patient's pain was immediately relieved. The patient had no complications or recurrence of symptoms and was undergoing regular check-ups every 6 months. LESSONS During climbing exercise, repeated high pressure causes damage of the hand and wrist joints in young patients. Chronic pain in this group must be carefully evaluated, and radiographs should be obtained for diagnosis and early treatment. Conservative treatment of these injuries has good results, and avoiding intensive power training avoids the risk of this injury.
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Affiliation(s)
- Sai-Won Kwon
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital, Cheonan
| | - Si-John Hong
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital, Cheonan
| | - Jae-Hwi Nho
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital, Seoul, Korea
| | - Sang Il Moon
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital, Cheonan
| | - Ki Jin Jung
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital, Cheonan
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13
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Maloney E, Zbojniewicz AM, Nguyen J, Luo Y, Thapa MM. Anatomy and injuries of the pediatric wrist: beyond the basics. Pediatr Radiol 2018; 48:764-782. [PMID: 29557490 DOI: 10.1007/s00247-018-4111-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/12/2018] [Accepted: 02/27/2018] [Indexed: 11/30/2022]
Abstract
Ligamentous injuries of the pediatric wrist, once thought to be relatively uncommon, are increasingly recognized in the context of acute high-energy mechanism trauma and chronic axial loading, including those encountered in both recreational and high-performance competitive sports. Recent advances in MR-based techniques for imaging the pediatric wrist allow for sensitive identification of these often radiographically occult injuries. Detailed knowledge of the intrinsic and supportive extrinsic ligamentous complexes, as well as normal developmental anatomy and congenital variation, are essential to accurately diagnose injuries to these structures. Early identification of ligamentous injury of the pediatric wrist is essential within the conservative treatment culture of modern pediatric orthopedics because treatment of these lesions often necessitates surgery, and outcomes often depend on early and sometimes aggressive intervention. In this article, we review MR arthrogram technique and pediatric wrist anatomy, and correlate appearances on MR and selected ligamentous pathologies of the pediatric wrist.
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Affiliation(s)
- Ezekiel Maloney
- Department of Radiology, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
| | - Andrew M Zbojniewicz
- Division of Pediatric Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, College of Human Medicine, Helen DeVos Children's Hospital, Advanced Radiology Services, Michigan State University, Grand Rapids, MI, USA
| | - Jie Nguyen
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yu Luo
- Department of Radiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, Nashville, TN, USA
| | - Mahesh M Thapa
- Department of Radiology, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
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Ali S, Kaplan S, Kaufman T, Fenerty S, Kozin S, Zlotolow DA. Madelung deformity and Madelung-type deformities: a review of the clinical and radiological characteristics. Pediatr Radiol 2015; 45:1856-63. [PMID: 26135644 DOI: 10.1007/s00247-015-3390-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 03/28/2015] [Accepted: 05/08/2015] [Indexed: 11/28/2022]
Abstract
Madelung deformity of the distal radius results from premature closure of the medial volar aspect of the distal radial physis, leading to increased volar tilt and increased inclination of the radial articular surface, triangulation of the carpus with proximal migration of the lunate and dorsal displacement of the distal ulna. The deformity is particularly common in Leri-Weill dyschondrosteosis, but it may also occur in isolation. True Madelung deformity can be differentiated from Madelung-type deformities by the presence of an anomalous radiolunate ligament (Vickers ligament). In this article, we will review the imaging characteristics of true Madelung deformity, including the common "distal radius" variant, the less common "entire radius" variant and "reverse" Madelung deformity. We will discuss the role of the Vickers ligament in disease pathogenesis and its use in differentiating true Madelung deformity from Madelung-type deformities arising from trauma or multiple hereditary exostoses. Surgical management of these patients will also be addressed.
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Affiliation(s)
- Sayed Ali
- Department of Radiology, Temple University Hospital, 3401 North Broad St., Philadelphia, PA, 19140, USA.
| | - Summer Kaplan
- Department of Radiology, Temple University Hospital, 3401 North Broad St., Philadelphia, PA, 19140, USA
| | - Theresa Kaufman
- Department of Radiology, Temple University Hospital, 3401 North Broad St., Philadelphia, PA, 19140, USA
| | - Sarah Fenerty
- Department of Radiology, Temple University Hospital, 3401 North Broad St., Philadelphia, PA, 19140, USA
| | - Scott Kozin
- Shriners Hospitals for Children, Philadelphia, PA, USA
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Paz DA, Chang GH, Yetto JM, Dwek JR, Chung CB. Upper extremity overuse injuries in pediatric athletes: clinical presentation, imaging findings, and treatment. Clin Imaging 2015; 39:954-64. [DOI: 10.1016/j.clinimag.2015.07.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 06/25/2015] [Accepted: 07/23/2015] [Indexed: 12/29/2022]
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16
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Kozin SH, Zlotolow DA. Madelung Deformity. J Hand Surg Am 2015; 40:2090-8. [PMID: 26341718 DOI: 10.1016/j.jhsa.2015.03.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 03/25/2015] [Accepted: 03/31/2015] [Indexed: 02/02/2023]
Abstract
Madelung deformity of the wrist is more common in females and is often associated with Leri Weill dyschondrosteosis, a mesomelic form of dwarfism. Patients with Madelung deformity often report wrist deformity resulting from the prominence of the relatively long ulna. The typical Madelung deformity is associated with a Vickers ligament that creates a tether across the volar-ulnar radial physis that restricts growth across this segment. The distal radius deforms in the coronal (increasing radial inclination) and the sagittal (increasing volar tilt) planes. There is lunate subsidence and the proximal carpal row adapts to the deformity by forming an upside-down pyramid shape or triangle. Treatment depends on the age at presentation, degree of deformity, and magnitude of symptoms. Mild asymptomatic deformity warrants a period of nonsurgical management with serial x-ray examinations because the natural history is unpredictable. Many patients never require surgical intervention. Progressive deformity in the young child with considerable growth potential remaining requires release of Vickers ligament and radial physiolysis to prevent ongoing deterioration Concomitant ulnar epiphysiodesis may be necessary. Advanced asymptomatic deformity in older children with an unacceptable-appearing wrist or symptomatic deformity are indications for surgery. A dome osteotomy of the radius allows 3-dimensional correction of the deformity. Positive radiographic and clinical results after dome osteotomy have been reported.
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Affiliation(s)
- Scott H Kozin
- Department of Orthopaedic Surgery, Temple University, Philadelphia, PA; Shriners Hospitals for Children, Philadelphia, PA.
| | - Dan A Zlotolow
- Department of Orthopaedic Surgery, Temple University, Philadelphia, PA; Upper Extremity Center of Excellence, Philadelphia, PA
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17
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Pritsch T, Moran SL. The management of congenital and acquired problems of the distal radioulnar joint in children. Hand Clin 2010; 26:579-91. [PMID: 20951907 DOI: 10.1016/j.hcl.2010.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pain in the ulnar aspect of the pediatric wrist is an uncommon problem; however, when pain does occur it is usually the result of antecedent bony trauma or an underlying skeletal abnormality, which may lead to ulnar-sided wrist pain of varying etiology. The clinician must to be able to identify these entities within the pediatric wrist in order to make the appropriate diagnosis and plan for surgical intervention to prevent ongoing damage to the distal radioulnar joint (DRUJ). This article reviews the etiology, clinical presentation, and treatment strategies for the management of the unique problems that can affect the pediatric and adolescent DRUJ.
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Affiliation(s)
- Tamir Pritsch
- Department of Orthopedics, 143 Avalon Cove Circle NW, Rochester, MN 55901, USA
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18
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Abstract
Madelung's deformity is a rare condition of the wrist characterized by a shortened distal radius with volar-ulnar curvature and a dorsally prominent distal ulna. It occurs predominantly in adolescent females who present with pain, decreased wrist mobility, and deformity. Although its aetiology remains unclear, its treatment is becoming more refined. Several different surgical techniques have recently been described in the literature. This review addresses Madelung's deformity and suggests an algorithm for management based on current literature and the authors' own clinical experience.
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Affiliation(s)
- A Dubey
- Department of Orthopaedic Surgery, Hand Division, NYU Hospital for Joint Diseases, New York 10003, USA
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19
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An overview of Madelung deformity. CURRENT ORTHOPAEDIC PRACTICE 2009. [DOI: 10.1097/bco.0b013e3181be9e9a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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MR Imaging in Congenital and Acquired Disorders of the Pediatric Upper Extremity. Radiol Clin North Am 2009. [DOI: 10.1016/j.rcl.2009.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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MR imaging in congenital and acquired disorders of the pediatric upper extremity. Magn Reson Imaging Clin N Am 2009; 17:549-70, vii. [PMID: 19524202 DOI: 10.1016/j.mric.2009.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Various congenital and acquired disorders can affect the upper extremity in pediatric and adolescent patients. MR imaging can provide unique anatomic and diagnostic information in the evaluation of many of these disorders, including inflammatory, infectious, neoplastic, and arthritic conditions. This article rounds out the issue on pediatric musculoskeletal MR imaging. It focuses on the evaluation of more common congenital disorders, and mainly sports-related injuries of the shoulder, elbow, and wrist in children. MR imaging can be more challenging in diagnosis of some of these disorders. Features of overuse injuries in skeletally immature athletes are a unifying theme throughout the article.
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22
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High resolution 3.0 Tesla MR imaging findings in patients with bilateral Madelung's deformity. Surg Radiol Anat 2009; 31:551-7. [PMID: 19225712 DOI: 10.1007/s00276-009-0476-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 01/29/2009] [Indexed: 10/21/2022]
Abstract
PURPOSE Madelung deformity (MD) is a rare, normally painful abnormality of the wrist and forearm which characteristically begins in adolescence. Usually the deformity appears between the age of 8 and 14 years, often progressing from initially mild functional pain to fatigue and loss of strength and finally, reduced mobility. We present the MR-findings in three patients with bilateral MD, using a high-resolution imaging protocol adapted for 3.0 Tesla (3.0 T) examinations. MATERIALS AND METHODS Wrist images of three patients were acquired at a 3.0 T Scanner (Gyroscan Intera, Philips Medical Systems, Best, The Netherlands), using a dedicated phased array coil. The imaging protocol consisted of coronal T1-weighted Turbo-spin-echo (T1w-TSE) and coronal and sagittal T2-weighted TSE sequences (T2w-TSE). RESULTS MR-images of these three girls demonstrated severe volar bayonet configuration of the forearms with a dorsal prominence of the ulnar head, also a curved distal radial articular surface with increased ulnar angulation, due to a deceleration of growth in the ulnar portion of the distal epiphysis. The proximal carpal row showed pyramidal configuration. Also visible was a prominent short radiolunate ligament, the so called Vickers ligament, which originates from the ulnar border of the radius, inserts into the volar pole of the lunate and likely contributes to carpal pyramidalization. Furthermore, the images demonstrated an anomalous hypertrophied and elongated volar radiotriquetral ligament which, to our knowledge, has been described elsewhere only in another case. CONCLUSION High resolution imaging at 3.0 T permitted a detailed analysis of the complex pathomorphology in patients with MD. Investing the better signal-to-noise ratio at higher field strengths into spatial resolution an excellent image quality could be obtained, depicting the Vickers ligament and the anomalous volar radiotriquetral ligament in this rare disease.
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Laffosse JM, Abid A, Accadbled F, Knör G, Sales de Gauzy J, Cahuzac JP. Surgical correction of Madelung's deformity by combined corrective radioulnar osteotomy: 14 cases with four-year minimum follow-up. INTERNATIONAL ORTHOPAEDICS 2008; 33:1655-61. [PMID: 19099303 DOI: 10.1007/s00264-008-0711-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2008] [Revised: 11/07/2008] [Accepted: 11/07/2008] [Indexed: 11/24/2022]
Abstract
Fourteen wrists in 11 girls, mean age 13.3 years (range 9-16) at surgery, were treated for Madelung's deformity. The presenting complaint was incapacitating pain. All were treated by radial closing wedge osteotomy and ulnar shortening osteotomy. The dorsal retinaculum was also surgically repaired in six cases. At a mean follow-up of 5.1 years (range 4-8.75), we observed improved range of motion in both flexion/extension and pronation/supination and absence of pain during daily activity. Radiographically, positioning of the distal radial articular surface and lunate subsidence were improved. Union was obtained after all osteotomies without secondary procedures. Posterior displacement of the ulnar head persisted in two wrists. Combined radioulnar osteotomy restored the anatomy to as near normal as possible. This technique provides satisfactory and encouraging results and does not compromise the surgical future of the wrist. However, longer follow-up is required to assess recurrence or possible long-term degenerative consequences.
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Affiliation(s)
- Jean-Michel Laffosse
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital des Enfants, avenue de Grande Bretagne, Toulouse, France.
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McCarroll HR, James MA, Newmeyer WL, Manske PR. Madelung's deformity: quantitative radiographic comparison with normal wrists. J Hand Surg Eur Vol 2008; 33:632-5. [PMID: 18694918 DOI: 10.1177/1753193408092496] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Four measurements, ulnar tilt, lunate subsidence, lunate fossa angle and palmar carpal displacement, on wrist radiographs of 26 patients with Madelung's deformity and 48 normal subjects were compared. The range of measurements on wrists with Madelung's deformity was wider than on normal wrists, with severe deformities having very abnormal values. Some Madelung's patients had values that were within the normal range for each of the four measurements. Measurement of the lunate fossa angle demonstrated the least overlap between normal wrists and wrists of patients with Madelung's deformity with only two in the normal range. A lunate fossa angle over 29 degrees may help identify early Madelung's deformity.
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Affiliation(s)
- H R McCarroll
- Shriners Hospital for Children, Northern California, CA, USA.
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25
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de Brito P, Metais J, Guilley C, Goguey B, de Courtivron B, Sirinelli D. Déformation de Madelung de l’enfant liée à la présence d’un ligament radio-lunaire anormal : à propos de 4 cas. ACTA ACUST UNITED AC 2007; 88:1887-92. [DOI: 10.1016/s0221-0363(07)78367-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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26
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McCarroll HR, James MA, Newmeyer WL, Molitor F, Manske PR. Madelung's deformity: quantitative assessment of x-ray deformity. J Hand Surg Am 2005; 30:1211-20. [PMID: 16344178 DOI: 10.1016/j.jhsa.2005.06.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Revised: 06/01/2005] [Accepted: 06/13/2005] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate 5 defined measurement techniques that are applicable to x-rays of Madelung's deformity: ulnar tilt, lunate subsidence, lunate fossa angle, palmar tilt, and palmar carpal displacement. The measurements rely on the longitudinal axis of the ulna and the carpal bones to determine drawing lines and avoid the distorted distal radius and its deformed lunate fossa. The reliability and reproducibility of the measurements is determined. METHODS Forty-eight sets of posteroanterior and lateral x-ray views of the wrist of subjects with the clinical diagnosis of Madelung's deformity were measured by 4 raters. Each rater made the 5 defined measurements on each pair of x-rays. Pairs of raters were compared for reliability using the Pearson correlation coefficient and Lin's concordance correlation coefficient. Two raters repeated the 4 reliable measurements a minimum of 6 months after the first measurements. Each rater's results were compared for reproducibility using Lin's concordance correlation coefficient. RESULTS Ulnar tilt and lunate subsidence have excellent reliability and reproducibility. Palmar carpal displacement has acceptable reliability and reproducibility. Lunate fossa angle has borderline reliability but excellent reproducibility. Palmar tilt has poor reliability. CONCLUSIONS Ulnar tilt, lunate subsidence, and palmar carpal displacement, as defined, are considered reliable and reproducible measurements for quantifying the severity of Madelung's deformity on x-rays. Lunate fossa angle is not sufficiently reliable for comparing preoperative and postoperative wrists but may prove useful in establishing an early diagnosis. Palmar tilt is not measured reliably on a lateral x-ray because of the superimposition of multiple structures on a lateral x-ray and the absence of the volar part of the lunate fossa in patients with severe Madelung's deformity. Advanced imaging techniques are needed to delineate the deformity of the distal radius in a lateral projection.
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Affiliation(s)
- H Relton McCarroll
- Shriners Hospital for Children Northern California, Sacramento, CA 94115, USA.
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27
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Bruno RJ, Blank JE, Ruby LK, Cassidy C, Cohen G, Bergfield TG. Treatment of Madelung's deformity in adults by ulna reduction osteotomy. J Hand Surg Am 2003; 28:421-6. [PMID: 12772098 DOI: 10.1053/jhsu.2003.50073] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Adult patients with Madelung's deformity may present with ulnar-sided wrist pain. Treatment often involves addressing the distal radial deformity. If there is focal wrist pathology and a positive ulnar variance, however, then an isolated ulnar-shortening osteotomy may provide symptomatic relief in these patients. The purpose of this study was to report our results of ulnar-shortening osteotomy without radial osteotomy in adult patients with Madulung's deformity. METHODS From 1988 to 2001 9 wrists in 9 adult patients with Madelung's deformity and ulnar-sided wrist pain underwent ulnar-shortening osteotomy. The distal radius abnormality was not addressed. All of the patients were women and the average age at the time of surgery was 34 years (range, 29-45 y). Two of the individuals were mesomelic dwarfs and the remaining 7 patients were otherwise normal. Surgery was performed after the patients failed at least 6 months of nonsurgical management. RESULTS All patients had improvement of their symptoms at an average follow-up evaluation of 42 months (range, 6-112 mo). All of the osteotomies united. One patient required replating for a delayed union. There were no infections and no ulnar carpal subluxation. Ulnar-positive variance correction averaged 4.4 mm. Postoperative range of motion and grip strength were equivalent to the contralateral wrist. CONCLUSIONS Ulnar-shortening osteotomy is a safe and reliable surgical procedure that can relieve ulnar-sided wrist pain in adult patients with symptomatic Madelung's deformity and positive ulnar variance.
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Affiliation(s)
- Roderick J Bruno
- Department of Orthopaedic Surgery, New England Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
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28
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Affiliation(s)
- June Villeco
- Out Patient Occupational Therapy Department, Montgomery Hospital, Norristown, Pennsylvania, USA.
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29
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Binder G, Fritsch H, Schweizer R, Ranke MB. Radiological signs of Leri-Weill dyschondrosteosis in Turner syndrome. HORMONE RESEARCH 2001; 55:71-6. [PMID: 11509862 DOI: 10.1159/000049973] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Leri-Weill dyschondrosteosis (LWD), a mesomelic short stature syndrome with Madelung deformity, was recently reported to be caused by SHOX (short stature homeobox-containing gene) haploinsufficiency. The loss of SHOX on Xp22.32, also called PHOG (pseudoautosomal homeobox-containing osteogenic gene), through structural aberrations of the X chromosome was also implicated in the short stature phenotype and some additional stigmata of Turner syndrome. The aim of this study was to systematically examine left-hand radiographs from Turner girls for the presence of signs of LWD. METHODS We retrospectively studied 168 left-hand radiographs from 54 patients with Turner syndrome (bone age >10.5 years) who were treated with rhGH and seen during the last 10 years in our clinic. For comparison, we analyzed 7 radiographs from 5 patients with LWD and 52 radiographs from 20 patients with GH deficiency. The shape of the distal radial epiphysis (triangularisation index = TI) and the carpal angle were quantitatively measured. In addition, we screened for the presence of a premature cleft fusion or an ulnar deviation of the articular surface of the distal radial epiphysis and for fourth metacarpal shortening. One of 54 Turner girls (2%) was affected with LWD and presented with Madelung deformity. RESULTS No milder forms of Madelung deformity were detected. However, there was a significant trend to a triangular shape of the distal radial epiphysis in Turner syndrome: the median TI was 2.7 in normal controls (range 1.8-3.7), 3.1 in Turner girls (range 2.0-6.3) (p < 0.001 against controls), and 6.0 in patients with LWD (range 3.5-11.0) (p < 0.001 against controls). CONCLUSIONS The triangularisation index did not correlate with the carpal angle (median 122.5
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Affiliation(s)
- G Binder
- University Children's Hospital and Growth Research Center, Tübingen, Germany.
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