Isolated wedge osteotomy of the ulna for mild Madelung's deformity

PURPOSE: Madelung's deformity is a characteristic pattern of anterior-ulnar bowing of the radius and a dorsally prominent ulnar head. Even if this deformity is associated with a certain degree of functional impairment, patients are satisfied with their function and mainly complain about the appearance of their wrists. The purpose of this study was to report a new surgical procedure (shortening combined with a slight anterior angulation osteotomy of the ulna) aiming to improve the appearance of the wrist and to relieve pain if present without compromising the function of the wrist. This technique is suitable for mild cases of Madelung's deformity. METHODS: This is a retrospective study of 4 wrists in 3 patients. All patients had a mild form of Madelung's deformity (without any dislocation of the lunate). Even if it was not their primary motivation to have surgery, all of the patients preoperatively experienced some wrist pain. An anterior angulation and shortening osteotomy of the ulna shaft was performed through a dorsal medial approach and fixed with a dynamic compression plate. RESULTS: At 24 months follow-up, all of the patients were satisfied with the appearance of their wrists and forearms. The distal radioulnar joint was congruent radiologically in all cases, and the range of active pain-free forearm rotation improved. CONCLUSIONS: This technique seems to be safe and reliable in mild cases of Madelung's deformity.     

Madelung's deformity: a spectrum of presentation

PURPOSE: To evaluate the hypotheses that all Madelung's deformity subjects have dyschondrosteosis (defined as short stature and mesomelia, in addition to Madelung's deformity) and to evaluate the concept that Madelung's deformity may affect the entire radius. METHODS: A radiographic and medical records review was performed for 26 subjects (46 extremities) with Madelung's deformity. The radiographs were assessed for radius and ulna length, sagittal radial bow, severity of the Madelung deformity, and radiocapitellar joint space. The sagittal radial bow and the radiocapitellar joint space were used to classify subjects according to whether the Madelung deformity was limited to the distal radius or involved the entire radius. RESULTS: Thirty-one extremities in 18 subjects were classified as having a distal radius Madelung deformity and 15 extremities in 8 subjects were classified as having an entire radius Madelung deformity. The radius and ulna length and subject height were significantly decreased compared with age- and height-matched normal values in both groups; the entire radius group was more severely affected. In addition, the entire radius group had more severe deformities with respect to lunate subsidence and ulnar tilt. All of the entire radius subjects and 9 of 14 of the distal radius subjects had dyschondrosteosis. CONCLUSIONS: Madelung's deformity presents as a spectrum. It may affect the entire radius or it may affect only the distal radius. Extremities with involvement of the entire radius have a shorter radius and ulna, decreased height, and a more severe deformity than extremities with involvement of only the distal radius. Additionally, most subjects with Madelung's deformity have dyschondrosteosis.     

Tumor location affects the results of simple excision for multiple osteochondromas in the forearm

BACKGROUND: The effectiveness of excision of osteochondromas in controlling the progression of forearm and wrist deformity remains an issue of controversy. The purpose of this study was to analyze the effectiveness of tumor excision in the correction of forearm and wrist deformity due to multiple osteochondromas in children, with an interpretation of the results based on different patterns of deformity. METHODS: Fourteen forearms in thirteen children with a follow-up of more than twenty-four months (average, fifty-three months) were included in the study. The forearms were divided into two groups on the basis of the location of the tumor and the pattern of deformity. In Group 1 (six forearms), the osteochondroma was only in the distal aspect of the ulna and caused compression of the radius. In Group 2 (eight forearms), tumors were in both the distal aspect of the ulna and the ulnar side of the distal part of the radius and were in contact with each other. Radial length, ulnar shortening, radial bowing, the radial articular angle, and carpal slip were measured as radiographic parameters. Ulnar shortening and radial bowing were expressed as a percentage of the radial length to make it possible to compare data between the individuals. Each parameter was evaluated before surgery and at the time of final follow-up. RESULTS: In Group 1, the percentage of ulnar shortening and the percentage of radial bowing had improved at the time of final follow-up; however, in Group 2, both the radial articular angle and the percentage of radial bowing had deteriorated significantly after the tumor excision (p = 0.049 and p = 0.017, respectively), even though the percentage of ulnar shortening showed no change. CONCLUSIONS: The effectiveness of simple excision of osteochondromas of the distal aspect of the forearm is influenced by the tumor location and is related to the pattern of the deformity. Simple tumor excision can correct the forearm deformity in patients with an isolated tumor of the distal part of the ulna. Conversely, in patients with tumors involving the distal part of the ulna and the ulnar side of the distal end of the radius, tumor excision alone is a less promising procedure for the correction of the deformity. LEVEL OF EVIDENCE: Prognostic Level IV.     

The Taniguchi classification in cases of multiple cartilaginous exostoses]

27 patients treated surgically at Child Orthopaedic Clinic of Pomeranian Medical Academy between 1974-1996 for multiple cartilaginous exostosis (Aclasia Diaphysealis Keith) were classified into three groups according to the Taniguchi classification. This classification is based on whether multiple cartilaginous exostoses are present on distal forearm. Group I--no involvement of the distal forearm (n = 2), in group II involvement of the distal forearm without shortening of either bone (n = 7) was stated. Group III consists of members with involvement of the distal forearm with shortening the radius or the ulna (n = 18). Groups were compared with regard to: number of lesions, distribution of exostoses in different body areas, age of onset of the Keith disease, height of children, presence of valgus deformity of the ankle, dislocation of the radial head and presence of exostoses around hip area. This classification should be useful in estimating severity of Keith disease, identifying cases at high risk for complications like dislocation of the radial and malignant transformation.     

Volar ligament release and distal radius dome osteotomy for correction of Madelung's deformity

PURPOSE: Madelung's deformity is usually recognized near the completion of skeletal growth and corrective osteotomy of the radius is frequently performed to treat the deformity and reduce pain. This study reviewed the clinical and radiographic results of a volar approach, ligament release, and dome osteotomy technique for treatment of this deformity. METHODS: Between 1990 and 2000, 26 wrists in 18 patients were treated with a volar ligament release and dome osteotomy of the distal radius. The average age of the patients at the time of surgery was 13 years. All patients were available for review at an average of 23 months after surgery. Radiographs before surgery and at final follow-up evaluation were analyzed for the extent of correction. RESULTS: All patients treated with this corrective osteotomy reported a reduction in pain and improved appearance. Patients showed improvements in forearm supination and wrist extension, with no loss of pronation or flexion. Improvements in the radiographic parameters of radial inclination and lunate subsidence also were observed. Four wrists required concurrent ulnar-sided surgery, and 3 additional wrists required staged ulnar shortening. One patient required a Darrach resection 3 years after the index procedure. CONCLUSIONS: The results of volar dome osteotomy provide improved range of motion, improved appearance, radiographic correction, and pain relief while preserving soft-tissue support for radial rotation around the distal ulna. Long-term follow-up evaluation is ongoing.     

Isolated Madelung's deformity: long-term follow-up study of five patients treated surgically

Five patients with isolated Madelung's deformity were reviewed with an average follow-up of 34 years after surgery. All the patients were female and their average age at surgery was 12.7 years, whereas the average age at follow-up was 53 years. The deformity was bilateral in four patients and unilateral in one, for a total of nine deformities. At diagnosis, in all the patients the typical radial deviation of the hand was observed, with dorsal prominence of the distal end of the ulna. Pain and limitation of the range of motion were present in all the wrists except two, which were painless but presented marked functional impairment. In no patient did we observe growth disorders of the other bones or deformities typical of osteochondrodysplasias. Surgical correction was sought by both the families and the patients mainly for functional reasons, although cosmetic improvement was also expected. The operation consisted of closing-wedge osteotomy of the distal radial metaphysis and either shortening osteotomy or resection of the distal ulna. At follow-up, the range of motion of the wrists was improved, and all the patients were pain-free and satisfied with the final results. No significant radiographic osteoarthritis was present in any of the operated wrists, although four of the five patients were above 50 years of age.     

Congenital radio-ulnar synostosis

Thirty-three patients with congenital radio-ulnar synostosis were examined. There was one familial predisposition. Chromosomal patterns were examined in seventeen patients and were normal. Bone maturation appeared normal. The radial deviation angle, in the patients whose distal radial epiphysis had closed, was elevated (Madelung's deformity). However, in the patients whose distal epiphysis maturation score was 8, it was not elevated. On the other hand, elongation of the ulna (plus variant) and/or dorsal dislocation of the distal end of the ulna was seen in early life. In terms of treatment, all attempts to divide the two bones failed. It was found that derotation of the nonwriting hand by an osteotomy through the proximal fusion mass was a useful procedure.     

Treatment of distal radioulnar disorders

Twenty-nine wrists of 29 patients were treated with three procedures: distal ulnar resection (Darrach's procedure), distal ulnar recession, or hemiresection-interposition arthroplasty. The indications were pain and limitation of motion associated with primary osteoarthritis of the distal radioulnar joint, derangement after distal forearm bone fracture, Madelung's deformity, and distal radioulnar sprain. The age of the patients averaged 48.3 years. Follow-up averaged 1 year and 9 months. Radiographic evaluations were done preoperatively and postoperatively. Relief of pain was good in the wrists treated by Darrach's procedure; however, diminished grip strength and wrist instability occurred. Relief of pain in the wrists treated by distal ulnar recession and hemiresection-interposition arthroplasty was inferior to that of Darrach's procedure; however, postoperative grip strength increased and wrist instability did not occur.     

Madelung's deformity: quantitative assessment of x-ray deformity

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.     

Bilateral spontaneous extensor tendon ruptures in Madelung's deformity.

Rupture of finger extensor tendons by attrition is an extremely rare complication of Madelung's deformity. We report a case of bilateral rupture in a previously symptom-free woman. The dorsally subluxed distal ulna was resected to prevent further rupture. The mechanism of injury, clinical and radiographic features, and treatment of this uncommon complication are reviewed.     

Spontaneous ruptures of the extensor tendons of the fingers in Madelung's deformity

Madelung's deformity is a congenital malformation with a slow clinical and radiological evolution and few complications. However, we have seen six instances of spontaneous rupture of the extensor tendons of the fingers related to the deformity of the inferior radio-ulnar joint. Treatment consisted of resection of the ulnar head, stabilisation of the distal ulna, and repair of the extensor tendons by tendon transfers. We discuss the possibility of avoiding the tendon ruptures by treating the deformity at an early stage.     

Three‐Dimensional In Vivo Analysis of Malunited Distal Radius Fractures With Restricted Forearm Rotation

Malunited distal radius fractures (DRFs) occasionally restrict forearm rotation, but the underlying pathology remains unclear. We aimed to elucidate the mechanism of rotational restriction by retrospective analysis of 23 patients with unilateral malunited DRFs who presented restricted forearm rotation. We conducted computed tomography during forearm rotation on both sides. Three‐dimensional (3D) bone surface models of the forearm were created, and 3D deformity of the distal radius, translation of the distal radius relative to the ulna, distal radioulnar joint (DRUJ) contact area, and estimated path length (EPL) of distal radioulnar ligaments (DRUL) during forearm rotation were evaluated. In total, 18 patients had dorsal angular deformities (DA group) and five had volar angular deformities (VA group). In the DA group, the closest point between the distal radius and ulna on DRUJ was displaced to the volar side during supination and pronation (p < 0.001); DRUJ contact area was not significantly different between the DA and normal groups. In bone–ligament model simulation, the EPL of dorsal DRUL was longer in the DA group than in the normal group (p < 0.001); opposite phenomena were observed in the VA group. In the DA group, translation of the distal radius in a volar direction relative to the ulna during pronation was impaired presumably due to dorsal DRUL tightness. Anatomical normal reduction of the distal radius by corrective osteotomy may improve forearm rotation by improving triangular fibrocartilage complex tightness and normalizing translation of the distal radius relative to the ulna. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1881–1891, 2019     

One-bone forearm procedure for partial defect of the ulna

Two cases of partial defects of the ulna in the growing child were successfully treated with the one-bone forearm procedure and followed up for 1 and 5 years, respectively. Stable elbow and forearm could be established by synthesis of the proximal part of the ulna and the distal part of the radius. Cosmetic and functional improvement was achieved in spite of a limitation of pronation-supination in the forearm. Longitudinal growth of the affected forearm was maintained during the follow-up period after correction at surgery.     

Pseudoarthrosis of the ulna in neurofibromatosis

Summary Four children suffering from neurofibromatosis with ulnar pseudarthrosis and progressive reabsorption of the middle and distal thirds of the ulna are reported. None had any pain or sensory loss, but all had progressive deformity of the forearm. Instability of the elbow and wrist were present in three cases, while one case showed good stability and function. A cross-union of the ulna with the radius to produce a one-bone forearm was accomplished using screw fixation and iliac bone grafting, and a one-bone forearm was achieved in three cases. Non-operative management was decided on in the patient with slow ulna reabsorption. The creation of a one-bone forearm is more likely to produce sound union, thus avoiding the need for further operations, while conservative management should be reserved for patients with a slowly progressive condition.     

Corrective osteotomies of the radius and ulna for supination contracture of the pediatric and adolescent forearm secondary to neurologic injury

PURPOSE: To present the authors' experience with internal fixation of the radius and ulna as a surgical option for correction of supination contracture of the forearm. METHODS: Twelve patients (13 limbs) had an osteotomy of the radius and ulna for a supination deformity secondary to a residual brachial plexus or spinal cord injury. Surgery consisted of proximal ulna and distal radius osteotomies combined with plate fixation. RESULTS: The average age of the patients at the time of surgery was 11 years. Five limbs had fixed supination deformities and 8 limbs lacked pronation beyond neutral. The average preoperative supination deformity (either fixed or measured at midarc) was 76 degrees. The average intraoperative correction was 86 degrees. The average follow-up period was 16 months. The average midrange resting position maintained at final follow-up evaluation was 2 degrees of pronation. All limbs ultimately obtained radiographic and clinical union of the osteotomy sites. Complications included 6 plate fractures; however, only 1 patient required revision internal fixation. CONCLUSIONS: The combination of a proximal ulna and distal radius osteotomy with internal fixation can provide excellent correction, but the implant must be strong enough to hold the osteotomies rigidly in the corrected position during the time needed for union. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Forearm post-traumatic deformities: Classification and treatment

Introduction

There is no classification for acquired forearm deformities. A clinical-radiographic study was conducted to classify these deformities and evaluate the results.

Materials and methods

Thirteen patients with forearm deformities following traumas or their treatment were included (11 men and two women, from 2000 to 2010). Mean age was 31 years (range 10–75 years). Initial treatment was conservative in five patients and surgical in eight patients. One segment was affected in seven patients (the radius in four patients, the ulna in three), and both segments were affected in six patients. Location assessment: 2 projections X-rays, including wrist and elbow. Deformity location: proximal, diaphisary, distal, defined with the abbreviation, in distal sense, R1, R2, R3 for the radius, and U1, U2, U3 for the ulna. Primary and secondary deformities were distinguished: secondary deformities occurred later in a different location than the primary one. Six patients were treated with plate and screws. An external fixator was used in six patients. One patient was treated with bone resection. Iliac crest bone graft was used in 10 patients, and vascularised fibula graft in one patient.

Results

The primary deformity affecting the radial diaphysis (R2) determined a secondary deformity in four patients: in the distal ulna (U3) with ulnocarpal dislocation in three patients and in the distal radius (R3) in one patient. Results of osteosynthesis treatment were excellent in one patient, satisfactory in four and unsatisfactory in one. External fixation was excellent in one patient and satisfactory in five. Bone resection was satisfactory in one patient.

Discussion

Surgical treatments with osteosynthesis are the major cause of acquired forearm deformities in adults. Location and aetiology of the deformities are essential for the surgical indication and the result. It is important to restore the length of the deformed segment, realigning the anatomical axis. X-rays enable clinicians to distinguish between primary and secondary forearm deformities.

Conclusion

Characteristics and locations of post-traumatic deformities were identified. The major location is diaphisary and distal, the elbow is rarely affected. The functional consequence is a limitation in the range of motion of the hand. The best results are achieved with short-term treatment.     

Madelung's deformity: treatment by osteotomy of the radius and Lauenstein procedure

A 22-year-old woman with Madelung's deformity was treated by radial osteotomy and a Lauenstein procedure. This technique allows near normal restoration of the distal radius architecture, support of the ulnar side of the carpus, maintenance of forearm pronation and supination, and a satisfactory cosmetic result.     

Posttraumatic radial club hand

Fifteen adult patients with an unstable ununited fracture of the distal third of the radius and severe radial deviation deformity resembling a radial club hand were retrospectively reviewed at an average of 25 months after operative treatment. There were eight women and seven men with an average age of 57 years (range, 33-79 years). The average duration of nonunion was 56 months (range, 6-252 months). Six patients had a concomitant fracture of the ulna and four had dislocation of the distal radioulnar joint. Three patients were treated with wrist arthrodesis and 12 with plate fixation and autogenous bone grafting. The distal ulna was excised and used for bone graft in eight patients. Correction of deformity was facilitated by z-lengthening of the brachioradialis and flexor carpal radialis in four patients and distraction histogenesis (llizarov) in two patients. One patient failed to heal the fracture and was treated with wrist arthrodesis. Functional alignment and use of the hand was restored in all patients.     

Rotational osteotomies for congenital radioulnar synostosis

In five children, six forearms with a fixed pronation deformity secondary to congenital radioulnar synostosis were treated by a derotation osteotomy of the distal radius and the midshaft of the ulna.There were three boys and two girls with a mean age of 4.9 years (3.5 to 8.25) who were followed up for a mean of 29 months (18 to 43). The position of the forearm was improved from a mean pronation deformity of 68 degrees (40 degrees to 80 degrees ) to a pre-planned position of 10 degrees of supination in all cases. Bony union was achieved by 6.3 weeks with no loss of correction. There was one major complication involving a distal radial osteotomy which required exploration for a possible compartment syndrome.     

Operations for forearm deformity caused by multiple osteochondromas

We reviewed 36 cases of forearm deformity caused by multiple osteochondromas in 30 patients and classified them into three types: Type I showed a combination of ulnar shortening and bowing of the radius secondary to osteochondromas of the distal ulna (22 forearms). Type II showed dislocation of the radial head, either with osteochondromas of the proximal radius (Type IIa, two forearms) or secondary to more distal involvement (Type IIb, five forearms). Type III had relative radial shortening due to osteochrondromas at the distal radius (seven forearms). Operations were performed on 16 forearms in 13 patients, with 92% of satisfactory results. For Type I deformity, excision of osteochondromas, immediate ulnar lengthening and corrective osteotomy of the radius are recommended. For Type IIa, excision of the radial head is necessary, and for Type IIb, we advise gradual lengthening of the ulna using an external fixator. Excision of osteochondromas alone gave good results in Type III deformity. Our classification gives a reliable indication of the prognosis and is a guide to the choice of surgical treatment.