Madelung's deformity is a rare disease of the wrist which affects mainly females during the adolescence growth spurt. Clinical presentation: radial deviation of the hand with prominence of distal end of ulna and a volar subluxation of the carpus. Various techniques for surgical management have been described until now, but still clear evidence to support the use of any single approach is lacking.
Best results in Madelungs deformity we can see, if correction of the radius was done before the age of 16. Vickers´ ligament plays an important role and if this accessory ligament is divided very early (before 11th year), nearly no deformity will result (but it´s very difficult to find these patients, only in genetic disorders inside one family (Lery-Weill -disease). I prefer open wedge osteotomy of the radius at the area of Vickers´ligament at the palmar ulnar border of the radius and internal fixation with plates and locking screws. Bone graft is not necessary in many cases.
Yes Martin, thank you very much for your comment. Vickers ligament causes the wrist to deform even more and purpose of this release is to decrease the tension and give the possibility of the distal radius correction during further growth.
Most of my patients are 13-15 years. Because of the Vickers´ ligament I always find a bone bridge at the palmar-ulnar aspect of the radius between epiphysis and diaphysis. In my opinion it is not necessary to cut the Vickers´ ligament at this age. But to correct the distal radius the best osteotomy runs always through this ligament. So I have seen the cross section of this ligament about 25 times in operations.
Vickers and Nielsen advocate early preventive epiphyseolysis with fat interposition combined with release of the Vockers ligament. J Hand Surg [Br] 1992:17; 401-407.
Computer assisted surgery can reduce overall operative time and be more operative precise in 3-D correction osteotomy to restores anatomic configuration.
Epiphysiolysis is only useful when you expect the growth plate is intact and will correct the deficit. In most cases this is not possible. You can correct the deficit much better by correction osteotomy. With computer you can do a mathematical - theoretical correction but in the patient there are so many limiting structures as tendons, nerves, ligaments, vessels, and so on. In most cases the mathematical aim will not be achieved. and a complete anatomical correctionis not possible if there is a deformation in the distal radius and the proximal row.
Thank you very much for your interesting answer Marin. It is very difficult to shape the graft into an appropriate 3-D configuration and also to take care about soft tissues structures specificities.
Premature closure of the ulnar sided part of the distal radial physis is associate with reduction in the number of clearly discernible chondrocyte columns. Shortening columns contain chondrocytes stacked side by side. Columns lost contain their usual regular horizontal progression. Nests of chondrocytes replace the abnormal columns.
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