Results of the operative treatment in Madelung's deformity]

Nine wrists in eight patients were treated surgically between 1988 and 2003 for symptomatic Madelung's deformity. The pain of involved wrist followed by forearm deformation fulfilled criteria for surgery. Closing wedge osteotomy of the distal radius were carried out eight times accompanied by shortening of the ulna (four patients), excision of the distal ulna (one patient), and no ulnar surgery (three patients). Pain relieved after surgery. The follow up period ranged from 1 to 9.5 years. No pour results were stated in subjective patient's estimation during final check up. Wrist appearance were stated to be satisfactory. Limitation of the range of motion concerning supination and pronation of the forearm were stated invariably. X-ray retrospective assessment of the inclination angle, lunate coverage and presence of arthritic changes were conducted. Time and method of surgical treatment for Madelung's deformity should be considered individually.     

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.     

Treatment of Madelung's deformity in adults by ulna reduction osteotomy

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.     

Madelung deformity: isolated ulnar wedge osteotomy

OBJECTIVES: Madelung deformity is defined as a partial closure of the medial half of the distal radial growth plate, with anatomical consequences (wrist deformity), and functional impairment (decrease range of motion, loss of grip strength, and wrist pain). We report a new surgical procedure including a shortening of the ulna combined with slight anterior flexion osteotomy aiming to correct the radio-ulnar dislocation and to improve the range of forearm rotation, without correcting the global deformity. METHODS: This was a retrospective study of four symptomatic wrists in three patients. The follow-up was 24 months. Patients were assessed clinically and radiologically pre and post operatively. The ulnar shaft was shortened and anteriorly flexed through a dorsal and ulnar approach and fixed with a fitted internal DCP plate. The aim of this osteotomy was to reduce the dislocated distal radio-ulnar joint. RESULTS: At 24 months follow-up, the function was considerably improved with a correction of the ulno-carpial conflict. The range of painfree forearm rotation improved. The post-operative views showed a correction of the dorsal dislocation of the ulnar head. CONCLUSION: This technique seemed to be safe and demonstrated good results in these four wrists. It should be proposed in patients with Madelung deformity and assessed prospectively.     

Indikation und Ergebnisse der Verkürzungsosteotomie der Ulna

A relatively or absolutely too long ulna leads always to pain in the wrist, so that a compensation in length of both forearmbones is achieved by shortening osteotomy. The gradual ulna shortening osteotomy, the stylectomy and the resection of the caput ulnae with or without radius transposition osteotomy are available as shortening operation. In 17 patients of the Gießener Unfallchirurgischen Klinik we performed in 14 cases a shortening osteotomy of the ulna and in 3 cases a resection of the caput ulnae. The shortening osteotomy lead in all cases to a reduction of complaints and to an improvement of the mobility of the wrist. Due to frequent arthropathy the resection of the caput ulnae should be taken more often into consideration in older people.     

Madelung's deformity: quantitative radiographic comparison with normal wrists

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.     

Madelung's Deformity: A Follow-Up Studg of 26 Cases and a Review of the Literature

Madelung's deformity, the history, aetiology, pathogenesis and prognosis, is discussed, on the basis of the literature. The author's material of 26 cases has been followed up. Thirteen of them were treated by resection of the ulna head or shortening of the ulna, with or without wedge osteotomy of the radius. The result was an improvement in pain and a cosmetic improvement, but mobility was unaltered. Spontaneous improvement in the symptoms is common, so that a waiting policy, and observation of the patient until growth ceases, is recommended.     

Corrective osteotomy for symptomatic increased ulnar tilt of the distal end of the radius

Twelve wrists in 10 patients with a mean age of 23.6 years were treated for symptomatic increased ulnar inclination of the joint surface with corrective osteotomy of the radius. Diagnoses included mild ulnar dysplasia, posttraumatic deformity, Madelung's disease, and multiple hereditary exostosis. All patients had radial-sided wrist pain and an ulnarly displaced arc of radioulnar deviation. Preoperative radiographs showed excessive ulnar inclination of the distal radius, ulnar carpal translation, adaptive carpal malalignment, and frequent distal radioulnar joint incongruency. The patients had decreased pain and improved wrist function at a mean of 5.1 years (range, 2-10 years) after surgery. Average radial deviation changed from 3 degrees to 16 degrees and ulnar deviation from 48 degrees to 29 degrees; flexion/extension and pronosupination remained unchanged. Realignment of the wrist was shown radiographically by a change of ulnar inclination of the radius from 33 degrees to 21 degrees, an increase in scaphoid height from 16.4 to 20.4 mm, and reversal of ulnar carpal translation as shown by an increase in lunate-covering ratio of 64% to 77%. Reduction of the ulnar inclination to normal values by corrective radial osteotomy restores a more physiologic range of motion, decreases symptomatic wrist pain, reverts adaptive carpal changes to normal, increases lunate coverage, and may prevent abnormal cartilage overload in the ulnar compartment of the wrist.     

Shortening and deformity of radius and ulna in children: correction of axis and length by callus distraction

Forearm deformities in children and adolescents may be congenital or developmental, or result from trauma; they may cause pain and decreased function of the wrist and hand. In this study we treated seven patients with forearm deformities (10 forearms) by callus distraction of either the radius or ulna using a monolateral external fixator after osteotomy. Target length was achieved in all cases. The results show significant improvement in range of motion of the forearm. All patients were satisfied with the appearance. There were no complications such as pin tract infection or neural impairment. In one case delayed ossification was resolved by alternating distraction and compression. The timing of correction depends on the implications of the deformity for the carpal bones and the function of the other forearm. Monolateral external fixation proved a versatile tool for correction of forearm deformity in children and adolescents, with a low complication rate.     

Simultaneous radial closing wedge and ulnar shortening osteotomies for distal radius malunion

PURPOSE: Closing wedge osteotomies are an attractive treatment option for distal radius malunion in patients with osteopenia; however, they require an ulnar head resection to accommodate closure of corrective osteotomy and to address the issue of ulnocarpal abutment. The literature contains little information on concomitant ulnar shortening osteotomy despite a physiologic solution. We report the functional and radiographic outcomes of 5 patients treated for symptomatic distal radius malunion with simultaneous radial closing wedge and ulnar shortening osteotomies. METHODS: All 5 patients were women aged 52 to 69 years (average, 61 years). Four patients had extra-articular radius fractures with dorsal angulation (20-22 degrees ) and shortening (3-7/mm); the other had the fracture with volar angulation (24 degrees ) and shortening (11 mm). Through a volar approach an appropriate amount of bone wedge was removed from the distal radius. A small volar T-plate was used to secure the osteotomized bone fragment. Six to 11 mm of ulnar shortening osteotomy was performed by using transverse osteotomy and compression plating technique with an AO compression device. RESULTS: In all 5 wrists healing of radial and ulnar osteotomies occurred less than 3 months after surgery. There were no postsurgical complications. Postsurgical radiographs showed that the volar tilt angle of the radius was reduced to normal range (range, 8-15 degrees ) in all wrists. The ulnar variance was 0 mm in 4 wrists and 2 mm in 1 wrist. There were significant improvements in pain, function, and range of motion at an average follow-up evaluation of 17 months. The average grip strength as a percentage of the opposite side improved from 30% before to 73% after surgery. CONCLUSIONS: This study showed that closing wedge osteotomy of the radius concomitant with ulnar shortening osteotomy is technically and functionally adequate. Our procedure is indicated for patients with osteopenia for whom opening wedge osteotomy of the radius is inadequate.     

Ulnar shortening osteotomy with a premounted sliding-hole plate

BACKGROUND: Ulnar shortening osteotomy represents a common procedure for various ulnar-sided wrist disorders but is still associated with complications like malrotation, angulation, or nonunion because of incomplete closure of the osteotomy gap. We describe the use of a newly developed palmarly placed sliding-hole dynamic compression plate that allows fixation of the ulna before the oblique osteotomy is carried out. METHODS: We performed ulnar shortening osteotomy on 27 consecutive patients. The indication was ulnar impaction syndrome in 25 patients and symptomatic ulnar plus variance secondary to malunited distal radial fracture in 2 patients. The mean preoperative ulnar variance was +2.1 mm (range, +1 mm to +8 mm). All patients were evaluated before and after surgery and graded with the Disability of Arm-Shoulder-Hand (DASH) scoring system. RESULTS: All 27 osteotomies healed uneventfully over an average of 9.2 +/- 2.1 weeks. The mean postoperative ulnar variance was -2.1 mm (range, -3.1 mm to 0 mm). There were significant improvements in DASH score, pain, and grip strength at an average follow-up of 8.1 months. Six patients complained of plate irritation. CONCLUSION: Favorable results suggest that ulnar shortening osteotomy using an oblique osteotomy and a premounted sliding-hole compression plate avoids malrotation and angulation and is associated with satisfactory outcomes. This device does not require an assisting device, which minimizes the surgical exposure of the ulna. Palmar placement of the plate seems to reduce hardware irritation.     

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.     

Long-term follow-up of surgical correction of Madelung's deformity with conservation of the distal radioulnar joint in teenagers

Eleven wrists with painful Madelung deformity in seven patients were corrected during adolescence by a closing wedge osteotomy of the radius and a shortening osteotomy of the ulna, with conservation of the distal radioulnar joint. At late follow-up (9.7 years) function was considerably improved. When the ulnar head was correctly relocated during operation, a new distal radioulnar space developed. Shortening of the ulna must be generous and combined with slight flexion at the osteotomy.     

Ulnar shortening for tears of the triangular fibrocartilaginous complex

Ten consecutive patients had their ulnas shortened for treatment of ulnar wrist pain associated with triangular fibrocartilaginous complex tears. Each injury was traced to a previous fall or an overuse syndrome. Conservative treatment failed. In all patients, x-ray films showed ulnar positive or neutral variance. The ulna was shortened an average of 2 mm. Frank ulnolunate abutment and/or cartilage degeneration was found in six cases. Follow-up averaged 23 months, and except for one patient in whom radiocarpal arthritis developed, the remaining patients were satisfied and returned to their work or previous level of activity. Relief of pain, grip strength, and range of motion were excellent, except for an average decrease in flexion of 25.8 degrees (p = 0.01). Hardware irritation was noted in six patients. These findings substantiate the use of ulnar shortening to relieve ulnolunate impingement in patients with ulnar positive or neutral wrists in whom ulnar wrist pain develops and who demonstrate triangular fibrocartilaginous complex tears after acute trauma and/or overuse syndromes.     

Experimental corrective scaphoid osteotomy for scaphoid malunion with abnormal wrist mechanics

Two cases of painful posttraumatic scaphoid malunion (hump-back deformity) associated with dorsal intercalated segmental instability deformity and limitation of wrist motion are presented. Carpal alignment and wrist motion improved after an experimental opening wedge scaphoid osteotomy with iliac bone graft and Herbert screw fixation. The scaphoid deformities (angulation and shortening) were effectively corrected.     

Otto W. Madelung and the recognition of Madelung's deformity

Madelung's deformity is an uncommon congenital condition of the wrist usually seen in adolescent girls. It first was documented in the 1800s and is characterized by a shortened radius that curves ulnarly and volarly, a prominent ulna head that projects dorsally from the wrist, and a triangular arrangement of the carpal bones. It is mostly an aesthetic deformity although functional problems and pain may prompt surgeons to undertake a variety of corrective surgical procedures with varying degrees of success. This challenging condition is encountered rarely in a hand surgeon's practice. Even more obscure than the condition is the physician it is named after: Otto Wilhelm Madelung, a distinguished and successful German surgeon who lived at the turn of the century. This article provides a historical perspective on the person and the condition that is still an enigma a century later.     

Reconstruction of forearm deformities in multiple cartilaginous exostoses

The management of complex forearm deformities in patients with multiple cartilaginous exostoses is controversial. The objective of this study is to look into the outcome of treatment with the combined use of ulna lengthening, radial osteotomy, and excision of exostosis in our six patients, who all had Masada type 1 deformity of the forearm. Clinical assessment was performed using the pre- and postoperative range of motion of the wrist, forearm and elbow. The chief symptom each patient had was noted as well as the demographic data of all patients. Radiological assessment was performed by checking the degree of negative ulna variance, the radial articular angle, and the degree of carpal slip. The degree of satisfaction of the patients and their parents were noted. Good clinical and radiological results were obtained at a mean follow-up of 2.5 years. All patients and parents were satisfied and there was no recurrence of deformity in the latest follow-up. The authors believe in early and aggressive treatment of Masada type 1 deformity of the wrist and forearm for multiple cartilaginous exostoses with a combination of excision of exostosis, ulna lengthening and radial osteotomy.     

Radial shortening for Kienb?ck disease

The cases of twenty-nine consecutive patients (thirty wrists) who had radial shortening for the treatment of stages I through IIIB Kienb?ck disease were reviewed to assess the results of this procedure. Thirteen patients (45 per cent) had a history of trauma, and all thirty wrists had a negative ulnar variance (average, 2.8 millimeters) on radiographs. All wrists were re-examined after an average follow-up of 3.8 years (minimum, two years). At that time, the pain had decreased in 87 per cent of the wrists. Extension of the wrist had improved an average of 32 per cent; flexion, 27 per cent; radial deviation, 30 per cent; ulnar deviation, 41 per cent; and grip strength on the affected side, 49 per cent. Analysis of the radiographs by computer digitization showed no significant changes in the amount of collapse of the lunate at the latest follow-up. In two wrists, there were complications at follow-up (excessive shortening of the radius and non-union of the radial osteotomy). Radial shortening is an effective treatment for Kienb?ck disease in wrists that do not have degenerative changes in adjacent carpal joints. Pain, range of motion, and strength can be expected to improve, but the radiographic appearance of the lunate changes little, if any.     

Treatment of ulnar impaction syndrome with the wafer procedure

Our objective was to evaluate the efficacy of wafer resection of the distal ulna (the wafer procedure) as treatment for ulnar impaction syndrome. Between 1995 and 1997, 26 patients were surgically treated for refractory wrist pain secondary to ulnar impaction syndrome. The diagnosis was based on physical examination, radiologic imaging, and wrist arthroscopy, and confirmatory pathoanatomy was identified at the time of surgery in all cases. The study population consisted of 18 women and 8 men, and patient age averaged 42 years. Follow-up averaged 27 months (range, 17-41 months). Twenty-three patients were completely satisfied with pain relief and the functional status of their wrists at final follow-up. Range of motion returned to baseline in the majority of cases, usually by 3 months, and grip strength increased an average of 11 kg (P < or = .005). The wafer procedure is an effective treatment alternative to ulnar-shortening osteotomy for ulnar impaction syndrome and avoids the risk of nonunion and hardware-related complications.