Best Way to Treat Madelung DeformityMadelung deformity of the wrist is a congenital (present at birth) deformity that can cause wrist pain, stiffness, and loss of motion. But the cosmetic appearance is what most often brings the child or teenager in to see a surgeon. The best way to treat this problem is unknown with many surgeons in disagreement, conflicting opinions, and a general lack of consensus.
In this article, two surgeons from the University of Washington (Seattle) Medical Center review this wrist deformity and offer their opinions and preferred treatment. Using X-rays of a 13-year-old patient, they show what the deformity looks like (e.g., pyramid shape of the wrist and bowing of the radius bone in the forearm). Females are affected four times more often than males and both wrists are usually involved.
Two distinct features of this problem include: 1) the presence of a ligament (Vickers ligament) that holds the lunate bone of the wrist to the bottom of the radius and 2) growth arrest at the growth plate (physis) where the radius joins the wrist. Vickers ligament is named after the physician who first identified this extra soft tissue structure. It is believed that the ligament may be the cause (or at least a contributing factor) to the deformity because of the pressure (compression) it places on the bones.
X-rays are also used to demonstrate changes made in several patients treated surgically for a significant Madelung deformity. The controversy over when to do surgery is a key feature of this discussion. The question comes up: should surgery be done to correct the appearance when there are no symptoms? If the patient does report pain and/or loss of motion, is surgery warranted if there is only mild loss of function? And what type of surgery should be done?
After describing various types of surgeries used by others (e.g., soft tissue releases, radial dome osteotomy and physiolysis, combined radial and ulnar osteotomies, isolated radial osteotomy, isolated ulnar osteotomy, arthroplasty), the authors offer their preferred treatment.
They suggest surgery should be done when there are limiting symptoms rather than just for cosmetic purposes. A growing child who has no symptoms should be watched and re-checked each year. Only when the deformity is getting worse, the wrist is unstable, and/or the wrist is jammed together should surgery be planned.
Type of surgery is still under debate and study. Factors that must be considered when planning a surgical procedure include age (whether the patient is still growing), the presence of a difference in bone length between the two bones of the forearm, and severity of the radial bowing. Three basic surgical approaches include: release/removal of the Vickers ligament with corrective osteotomy, wrist arthroplasty (joint replacement), or arthrodesis (wrist fusion).
Because there just isn't enough evidence to guide management of this rare condition, more studies are needed to identify the best treatment approach. Finding successful nonsurgical ways to treat the problem is always preferred in the growing child. Early joint replacement is not advised because of the limited time the implant will last, thus requiring additional surgery later.
Surgery that does not improve wrist motion or relieve pain may not be the best way to treat Madelung deformity. Patient preferences and dissatisfaction with the appearance of the forearm and wrist are important considerations as well. Older adults who have experienced additional complications from this condition (e.g., tendon rupture, wrist subluxation or dislocation) may require surgical reconstruction of the wrist.
Andrew C. Ghatan, MD, and Douglas P. Hanel, MD. Madelung Deformity. In Journal of the American Academy of Orthopaedic Surgeons. June 2013. Vol. 21. No. 6. Pp. 372-382.
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