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Age / Sex : 15 / F
Chief complaint : right
wrist pain (onset: 6MA)
What is your impression?
Two weeks later, you can see the final diagnosis with a brief discussion of this case. (Please submit only one answer)
Courtesy: Moon
Sung Gyu, Konkuk University Medical Center
Diagnosis: Madelung deformity
Discussion
Findings:
CR:
increased volar tilt, increased inclination
of the radial articular surface, triangulation of the carpus with proximal
migration of the lunate (“V-shaped” proximal carpal row), dorsal displacement
of the distal ulna, physis closure of the medial volar aspect of distal radius
MR:
physis closure of the medial volar aspect of
distal radius, anomalous hypertrophic volar radiolunate ligament (Vickers
ligament) (white arrow)
Discussion:
Madelung deformity results from premature
closure of the medial volar aspect of the distal radial physis. Madelung
deformity demonstrates a 4:1 female predominance and increased prevalence among
patients with Leri-Weill dyschondrosteosis, and it is classically bilateral and
symmetrical Madelung-type deformities may occur in the setting of isolated or
repetitive trauma, Turner syndrome, multiple hereditary exostoses, and Ollier
disease when there is an interruption of the medial volar aspect of the distal
radial physis.
Associated abnormalities of the ulna,
carpal bones, articular cartilage and tendons arise from radial growth failure
and resulting deformity. Congenital Madelung deformities are characterized by
the presence of an anomalous volar radiolunate ligament (Vickers ligament).
Vickers ligament is an anomalous hypertrophic volar radiolunate ligament
thought to tether the medial radial metaphysis and triangular fibrocartilage
complex (TFCC) to the palmar surface of the lunate. The ligament restricts the
medial and volar growth of the radius by exerting a compressive effect on the
physis, resulting in the characteristic radiographic features
Radiographic features demonstrate increased
volar tilt and increased inclination of the radial articular surface,
triangulation of the carpus (“V-shaped” proximal carpal row) with proximal
migration of the lunate and dorsal displacement of the distal ulna.
Additional features of Madelung deformity
can be seen with MRI. A bony physeal bridge resulting from early closure of the
medial volar physis will be more readily apparent on MRI but can also be
detected on radiographs. In addition to Vickers ligament, MRI may reveal an
anomalous hypertrophied and elongated volar radiotriquetral ligament. The TFCC
typically demonstrates a progressively oblique orientation secondary to the
radial deformity and may become thickened. This abnormal morphology subjects
the TFCC to increased stress and may predispose patients to TFCC tears
References:
Ali S, Kaplan S, Kaufman T, Fenerty S, Kozin S,
Zlotolow DA. Madelung deformity and Madelung-type deformities: a review of the
clinical and radiological characteristics. Pediatr Radiol. 2015
Nov;45(12):1856-63
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