31 Y Madelung case - Mohammed Jafar (2024)
This lady visited me last week. She has always been told that she is different and she has to live with it. She has a good ROM but functional pain. I am not sure that surgery would help her definitely (as my mentor used to say: All the surgeries were relevant except the very first one..)
Any good advice.
Short presentation with x-ray. The CT sequence and 3D are separate
Thank you
Mohammed Jafar
Denmark
Please look at the PDF file joined and 2 shortes movies
IMHO not clear Madelung in my eyes. Maybe could be called "Madelung like deformity".Would need to perform more specific anamnesis and status. Where is the pain? When? Which tasks/movements? And so on.
If the patient can cope with the pain, would do nothing. If not, would start with conservative treatment: physiotherapy, splinting, avoid pronation, cortisone injection 1-2 times, and so on.
If conservative treatment not enough, MRI. Probably patients problems are from ulnar impactation syndrome. Then if surgery needed arthroscopy and USO.
Mikko Räisänen
Dear Mikko
Thank you very much for your replay. Maybe I did not make it very clear
The condition has always been like that, no "new" pain. Somebody took the x-ray of hand/wrist during genetic test of her son and sent her further to me.
Clinically I found the only pain on the left DRUJ which was lax. Negativ watson and fovea-test and no pain on movement at the clinic. Her pain comes when and after she uses her hand daily....
I doubt that any intervention would be of effective help, because of the chronicity and the shape of the bones. So I actually do not know what to do. MJ
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I disagree with the Madelung diagnosis, since Madelung deformity features some findings I don't see in the CT scan, namely, pronounced ulnar - radial tilt, distal radioulnar incongruence, shape modifications of the proximal Gilula arch (like a "shield" shape of the carpus), and an excessive flexion tilt of the radial articular surface which in time alter the radio-luno-capitate axis.
Hence, it is necessary to asses some provocative tests (Watson test, ballotment test, fovea test, etc.) in order to focus to a more precise clinical diagnosis. Afterwards, maybe a MRI study should be performed to rule out some injuries related with more specific pain causes.
I wouldn't call any treatment for this patient at this moment because some important clinical data are lacking.
Miguel Hernandez
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I’m not sure that this wrist is a Madelung’s deformity. Checking the x-ray and CT-scan I see an important radial tilt of the distal radius with an ulna plus, but it is not the shape we are use to see in the MD.
Even the description of the anatomy, the most important item we should take in count is the physical examination.
It doesn’t matter how much deformity is in the wrist, the only way to treat correctly this and any patient is find out where are the symptoms and after that, correlate the clinical examination with the information obtained with the x-ray, MRI, CTscan…
We can hypothesize with the presence of an ulnar impact syndrome or an DRUJ instability, but if there is no pain in the ulnar border of the wrist and the stability test of the DRUJ are negative…don’t treat it.
If there is a global annoyance arround the wist probably there are nothig we can offer to the pacient in therms of surgery.
Treat the symptom not the picture.
If any other clinical examination brigs you more information let us know.
Dr Marc Garriga
Barcelona-Spain
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Hi Mohammed,
I would agree with you that this a form of Madelung’s. As pointed out by Miguel, it’s not a case of classic Madelung’s. However less common variants of the problem have been described, such as dorsal and central Madelung’s, where the sagittal deformity is reversed or minimal, but the increased radial inclination of the lunate fossa and positive ulna variance are present.
She has some increased volar tilt, especially of the lunate fossa, suggesting a developmental problem with the volar ulna physis.
If she has a functional problem, I think it is worth considering the possible common pain generators that go with Madelung’s, namely ulno-carpal abutment and Vicker’s ligament. The DRUJ won’t be normal, but that is not really reversible.
If you did get as far as considering surgery, perhaps you would consider:
1) excision Vicker’s ligament
2) dome osteotomy of radius to decrease dorsal tilt and radial inclination
3) USO. Usually I would do this as a second procedure in the 15% or so of patients who aren’t relieved of their symptoms by 1+2.
These days I’d probably add an arthroscopy to identify any lunate chondral lesions and TFCC defect. It may help understand what’s going on, but won’t change the outcome that much otherwise.
Nick Smith
Australia
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A very young patient is a Madelung Deformity, I would say mild to moderate. Non-dominant hand. Pain can be further defined as Sd of impigment or distal radiocubital
I see that it has arthrotic-type changes in the joint surface I would not propose any surgery for now. Physiotherapy and wristband only for RCD at work And adapt her work to his wrist.
If she have pain. Evaluate RCD osteoarthritis well
Its de radio triple- osteotomy If there is no arthrosis and ist was there --//Sauce Kapanji I like it.
Thank you for this case.
Militza Murúa
Chile Valparaíso
