Saturday, February 13, 2010

Madelung's deformity


Pathogenesis (Brailsford):
 Stunted development of inner third of the growth cartilage at the lower end of the radius, due to still unknown cause.
 Growth of the outer two-thirds continues and, as a result, the radial shaft is bowed backwards, the interosseous space is increased, there is overgrowth of lower end of ulna and is subluxated backwards.

Soft tissue changes:• Abnormal tethering of soft tissues from the distal radius to the carpus and ulna.
• These have included aberrant ligaments and pronator quadratus muscle insertions
• Hypertrophy of the palmar ligaments, including the radiotriquetral and the short radiolunate ligaments and an anomalous volar ligament(Vicker’s ligament)

Clinical Features:

 Often bilateral, hence disability may not be identified early and hence late presentation is common
 Often seen for the first time in adolescence.
 Females>males.
 Early cases: mild symptoms of ulnocarpal impaction with power grip activities, and distal radioulnar joint incongruity with forearm rotation
 Flexion may be increased; other movements are restricted and may be painful.
 May be associated with Dyschondrosteosis (Leri Weil syndrome), Turner’s syndrome, Achondroplasia, Ollier’s disease

Vender and Watson Classification:
a) Post traumatic
b) Dysplastic
c) Genetic
d) Idiopathic

 Steep ulnar slope and deficient ulnar margin of radius
 Lunate uncovered.
 The carpus subluxates ulnar and palmarward and appears wedge shaped (lunate lies at the apex of the wedge)
 Increased width between the distal radius and ulna.
 Relatively long ulna compared to radius (positive ulnar variance).
 Decreased carpal angle.
 Triangularization of the distal radial epiphysis.
 Carpus migrates more proximal into the increasing diastasis between the radius and the ulna


• In recent or acute cases, dorsiflexion of the wrist-maintained by a full arm plaster for 4 weeks.

Indications for surgery: Acute pain and deformity

Early presentation:
• In early-detected cases distal radial epiphysiolysis is done (Vickers and Nielsen et al.)
• Epiphysiolysis involves resection of the abnormal volar, ulnar physeal region of the radius and fat interposition. At the same time, any aberrant, tethering anatomic structures are excised
• Early presentation with marked deformity and complete lack of a lunate fossa for carpal support, needs combined radial and ulnar osteotomies. Alternatively ulnar and radial epiphysiodesis maybe done

Late presentation:
• Osteotomy of the lower end of the radius may be done. Options include dome osteotomy, dorsal radial closing-wedge osteotomy, or volar opening-wedge radial osteotomy and bone grafting
• Ulnar shortening procedure like the Suave-kapandji maybe useful, though there may already be deterioration of the articular cartilage, wrist ligaments, or triangular fibrocartilage, resulting in continued pain and limitation of motion postoperatively..

1. Vickers D, Nielsen G. Madelung's deformity: treatment by osteotomy of the radius and Lauenstein procedure. J Hand Surg [Am] 1987;12(2):202-204
2. Ranawat CS, DeFiore J, Straub LR. Madelung's deformity. An end-result study of surgical treatment. J Bone Joint Surg Am 1975;57(6):772-775


  1. Madelung deformity
    abnormality of palmar ulnar part of distal radial epiphysis which leads to progreesive palmar and ular tilt at distal radial articular surface with dorasal subluaxation of distal ulna.

    Associated with:
    Mesomelic dwarfism
    multiple exostosis
    olliers disease

  2. The incidence of epiphseal deformity in immature Gymnasts suggests that a volar and ulnar vector due to the normal distal radial tilt might add some light on patholgy. I am sorry that I cant remember the reference but is something which came up for review in about 1995.

  3. i am honoured sir for you to comment on my blog...

  4. It was very informative reading through your blog. I have a mild madelung deformity and also a 9 mm cyst in my lunate bone. The pain I am experiencing sounds alot like the pain described by this deformity.... In 1 month I am having surgery on the cyst and am worried the pain won't go away. I have had just about evey scan possible and a great doctor.

  5. i hav a similar pt. 12yrs girl with B/L wrist pain , x rays show madelungs def, BUT MRI shows madelungs with cystic lesion in the lunate ?lunatomalaciaR>L , my queries r,
    a. does cystic lesion coexists with madelungs or is it separate entity?
    b. do i have to treat madelungs alone or treat cystic lesion simultaneously?