Radiological Category Musculoskeletal Principal Modality 1 General Radiography

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Radiological Category: Musculoskeletal Principal Modality (1): General Radiography Principal Modality (2): None Case Report

Radiological Category: Musculoskeletal Principal Modality (1): General Radiography Principal Modality (2): None Case Report # 0921 Submitted by: Christopher Z Lam , M. D. Faculty reviewer: Manickam Kumaravel, M. D. Date accepted: 06 March 2012

Case History 81 year old female status-post assault with head injury found unresponsive. Physical

Case History 81 year old female status-post assault with head injury found unresponsive. Physical exam reveals a wrist deformity that is worked up radiographically.

Radiological Presentations

Radiological Presentations

Radiological Presentations

Radiological Presentations

Test Your Diagnosis Which one of the following is your choice for the appropriate

Test Your Diagnosis Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. • Acute ulnar dorsal dislocation and dorsal intercalated segment instability • Chronic prior Galeazzi fracture with malunion • Paget disease • Maffucci syndrome • Madelung deformity • Radioulnar synostosis

Findings and Differentials Findings: • • • Nothing acute Dosal subluxation of the ulnar

Findings and Differentials Findings: • • • Nothing acute Dosal subluxation of the ulnar head Apparent positive ulnar variance Radial lateral bowing Decreased carpal angle with medial tilt and ulnar inclination of the distal radiocarpal articular surface Triangular configuration of the carpus with proximal migration of the lunate and associated volar carpal subluxation Differentials: • This case is classic for Madelung Deformity • Some other causes of forearm deformity include: • Prior fracture with malunion • Radioulnar Synostosis • Paget disease • Maffucci Syndrome

Discussion Madelung Deformity • Congenital developmental deformity caused by focal abnormal growth of medial

Discussion Madelung Deformity • Congenital developmental deformity caused by focal abnormal growth of medial volar distal radius physis • Presents in childhood with pain at wrist, fatigue, and limited motion that worsens throughout adolescence • Can be idiopathic or associated with Dyschondrosteosis (Leri-Weill), Turner Syndrome, Mucopolyusaccharidoses, Multiple Hereditary Exostosis • Treatment is conservative (bracing) or surgical (rarely) Classic radiographic findings (all related to failure of medial volar distal radial physis) – Dorsolateral bowing curvature of the distal radius – Ulnar inclination of the distal radiocarpal articular surface – Dorsal subluxation of the ulnar head – Apparent positive ulnar variance – Widening of distal radioulnar joint These forearm deformities cause the carpus to wedge into the deformity: – Triangulation of the carpus with proximal and volar subluxation of the lunate – Carpus follows the radius

Discussion Radiographic Measurements • In subtle cases, measurements can help with the diagnosis of

Discussion Radiographic Measurements • In subtle cases, measurements can help with the diagnosis of Madelung Deformity • If suspected, any single positive measurement makes the diagnosis 109 o 43 o o tt n ge x ro al id ho p a d an te na lu sa sc im p nt e ng Ta n Ta ad or fos lun t B A 90 o – 43 o = 47 o Carpal Angle < 130 o ial 48 o ate Ulnar Tilt > 33 o (Ulnar tilt = 90 o – A) 90 o – 48 o = 42 o Lunate Fossa Angle > 40 o (Lunate Fossa = 90 o – B)

Discussion Radiographic Measurements • In subtle cases, measurements can help with the diagnosis of

Discussion Radiographic Measurements • In subtle cases, measurements can help with the diagnosis of Madelung Deformity • If suspected, any single positive measurement makes the diagnosis 23 mm 8 mm Lunate Subsidence > 4 mm (distance from proximal lunate to line through distal articular ulna perpendicular to longitudinal ulna) Palmar Carpal Displacement > 20 mm (distance from most palmar aspect of lunate or capitate to line perpendicular to mid-longitudinal ulna)

Discussion: Differentials Prior fracture with malunion • Focal deformity with lack of additional findings

Discussion: Differentials Prior fracture with malunion • Focal deformity with lack of additional findings • Bowing deformity in young children Radioulnar synostosis • Congenital or post-traumatic • Fusion of proximal radius to ulna • Small bones Paget disease • Bony expansion, thickened cortex, coarse trabeculae • Bowing more common in lower extremities Maffucci syndrome • Multiple enchondromas with soft tissue cavernous hemangiomas • Can lead to metadiaphyseal deformities with forearm shortening

Diagnosis Madelung Deformity.

Diagnosis Madelung Deformity.

References Mc. Carroll HR Jr, James MA, Newmeyer WL 3 rd, Manske PR. Madelung's

References Mc. Carroll HR Jr, James MA, Newmeyer WL 3 rd, Manske PR. Madelung's deformity: diagnostic thresholds of radiographic measurements. J Hand Surg Am 2010 May; 35(5): 807 -12. Zebala LP, Manske PR, Goldfarb CA. Madelung’s deformity: a spectrum of presentation. J Hand Surg Am 2007 Nov; 32(9): 1393 -401. Stehling C, Langer M, Nassenstein I, Bachmann R, Heindel W, Vieth V. High resolution 3. 0 Tesla MR imaging findings in patients with bilateral Madelung’s deformity. Surg Radiol Anat 2009; 31: 551 -557.