Age / Sex : 32 / F

Chief complaint : Right wrist pain

What is your diagnosis, and what structure is the white arrow pointing to?


Two weeks later, you can see the final diagonosis with a brief discussion of this case (Please submit only one answer).

Discussion

Answer: Madelung deformity with Vickers ligament.

Findings:

 Radiograph:

1) ulnar and volar curvature of the distal radius,

2) increased inclination of the distal radius

3) triangulation of the carpus with proximal migration of the lunate

MRI

 A hypointense band-like structure is noted bridging between the ulnar border of the radius and the lunate on both coronal and sagittal T2-weighted image, the so called Vickers ligament.

Differential Diagnosis: .

Discussion:

Madelung deformity is caused by an arrest of epiphyseal growth of the ulnar and volar portion of the distal radius, which leads to dorsal and radial bowing of the radius. It can be bilateral in 50-66% of patients. Females are more commonly affected than males.

Radiographs show radial and volar bowing of the distal radius, increased volar tilt of the distal radial articular surface, and an exaggerated ulnar tilt of the distal radius.and a widened distal radioulnar joint, The carpal bones wedge into the triangular deformity created by the distal radius, creating a V-shaped configuration.

Madelung deformity is treated conservatively if asymptomatic. Surgical correction may be needed in symptomatic cases (i.e. physiolysis with release of Vickers ligament, radial corrective osteotomy with or without distal ulnar shortening osteotomy, DRUJ arthroplasty)

References:

1. Kim, H. K. (2009). Madelung deformity with Vickers ligament. Pediatric radiology, 39(11), 1251


2. Stehling, C., Langer, M., Nassenstein, I., Bachmann, R., Heindel, W., & Vieth, V. (2009). High resolution 3.0 Tesla MR imaging findings in patients with bilateral Madelung’s deformity. Surgical and radiologic anatomy, 31(7), 551-557


3. Kozin, S. H., & Zlotolow, D. A. (2015). Madelung deformity. Journal of Hand Surgery, 40(10), 2090-2098.


4. Dubey, A., Fajardo, M., Green, S., & Lee, S. K. (2010). Madelung’s deformity: a review. Journal of Hand Surgery (European Volume), 35(3), 174-181.