Definition
Growth arrest of the ulna and volar aspects of the distal radius
Progressive ulnar and volar tilt of distal radial surface
Epidemiology
Rare
Autosomal dominant with incomplete penetrance
- more common in females
- usually bilateral
Etiology
Volar-ulnar radial physeal arrest
Carpal tether / Vicker's ligament
Vicker's ligament
Anatomical variant of volar radiocarpal ligament
- thick cord / fibrous band
- radial metaphysis proximal to radial epiphysis
- attaches to lunate and TFCC
Farr et al J Hand Surg Eur 2021
- 75 operative cases of Madelung's
- Vicker's ligament present in 85%
Association
Turner's Syndrome (45 X / XO)
DIfferential diagnosis
Post traumatic distal radial growth arrest
Enchondromatosis (Ollier's)
Hereditary Multiple Exostoses
Clinical
Palmar inclination of the wrist with prominent ulna
Not apparent in childhood - becomes obvious after adolescent growth spurt
Reduced dorsiflexion +/- rotation
Commonly asymptomatic with good function
X-ray
Increased obliquity of the distal radius
Dorsal subluxation of ulna
Inverted triangle shape of proximal carpal row
Lunate subluxed between radius and ulna
MRI
Vicker's ligament
Operative management
Indications
Pain / reduced function
Cosmetic deformity
Options
Skeletally immature
Excision Vicker's ligament + Epiphysiolysis of fused physis with fat graft
Epiphysiodeses of distal ulna
Otte et al J Hand Surg Am 2019
- 12 wrists with Madelung's deformity
- mean age 7.5 years
- Vicker ligament release and radial physiolysis
- 83% improvement radial inclination
- no worsening deformity
Skeletally mature
Distal radius osteotomy +/- ulna shortening osteotomy
- dome osteotomy + ligament release in 26 Madelung's deformity
- mean age 13
- improvement in pain, cosmetic appearance, and range of motion
Distal radius osteotomy