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Journal of Hand Surgery (American) / Vol 31A, No 2, February 2006
Anjali S. Arora, Kevin C. Chung
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Surgeons have described and performed surgery for this condition since the mid 1800s and it is accepted widely that Guillaume Dupuytren (13) documented the first case in his 1834 lecture on clinical surgery at the Hospital of Paris.(1) Dupuytren (13) published his observations but he did not propose practical explanations for the conditions that he saw.(13,14) In his lecture he described the palmar subluxation of the hand and the deformation of the wrist, noting that patients experienced a lack of wrist strength but no pain.
Dupuytren (13) treated his patients with ulnar splints, which reportedly corrected the deformity.
Years later Malgaigne,(15) a French surgeon known for his writing and editing ability and for his Treaty of Fractures and Luxations, also observed a case of this deformity and published his findings in 1855.(1,14) Not only did he describe the subluxation of the hand and the dorsal projection of the ulna but he also wrote that the wrist became normal once the patient discontinued heavy labour for 18 months as a bricklayer.(5,15) Others (l,5,9,16) also observed selected cases of this condition before Madelung.
Although he was not the first to describe or document the disease, Madelung received the honour of having the condition named after him because he was the first to write a complete and accurate description of the wrist deformity and to propose a cause and recommend treatment.
In his lecture at the surgical congress in 1878, Madelung (1) stated that the descriptions of the deformity documented in the literature were neither accurate nor complete.
He described his own observations, treatments, and etiology, along with providing a complete review of the literature on the topic, recognizing renowned surgeons of the time who contributed to the knowledge of the disorder: Dupuytren, Malgaigne, Nelaton, Busch, and Weber.(1) According to Madelung's clinical observations, this deformity of the wrist has the following characteristics: "Under the normal, rather stretched skin, the distal end of the ulna juts out clearly.
The styloid process and articular surface are recognizable and become apparent by feel.
The hand, for itself alone regarded, is normal, but it has dropped forward.
The widest diameter of the wrist is increased almost by double.
..[and] free large parts of the surface of the radius can be felt upon dorsiflexion.
...The whole lower epiphysis of the radius of the deformed side is also angulated volarwards."(1,17) In addition Madelung noted that the deformity limited the patient's range of motion, primarily supination and extension, and that some patients expe- rienced pain.
Madelung believed that the subluxation of the wrist occurred from repeated motions over a period of 1 to 2 years because none of his patients had symptoms at birth or experienced traumatic incidents that would have caused such a disorder.(l) He suggested that repeated motions overloaded and disturbed the growth of the joint and that the deformity resulted when the joint was predisposed to malformation.(l,5) Madelung recognized that the deformity was twice as common in women than it was in men and that the average age at onset of symptoms was 13 years.(l,5) Few of his patients experienced pain but those who did were an average of 23 years old when the pain began.
Most cases of Madelung's deformity appear bilaterally; Madelung and his predecessors encountered few patients with unilateral disease.(l) Nielsen,(5) after a review of the literature and his own follow-up study of 26 patients, suggested that unilateral deformity occurs only when trauma is the cause.
Madelung' s clinical findings are relevant today.
It now is known that the trait has a hereditary component transmitted in an autosomal-dominant fashion. (7,10). Madelung's and Madelung's-like deformities have been divided into 4 separate categories: acquired or posttraumatic, dysplastic (as with dyschondrosteosis), genetic, and idiopathic.(18-20). Madelung observed only acquired deformities, which are those deformities with very mild or abnormal physical findings, are unilateral, or are found in patients with a history of repetitive stress and/or injury.(4,19) Madelung and other surgeons of his time experimented with different treatments to reduce the wrist subluxation.
The goals of surgery were to gain range of motion, reduce pain, and correct the deformity.
Madelung found that discontinuing repetitive motions or manual labour would decrease the pain.
It was difficult, however, for a physician to deprive a worker of the use of their hands in 19th-century Germany.
Two German surgeons, Weber in 1859 and Busch in 1864, attempted to correct the deformity surgically by dividing the flexor carpi ulnaris and the palmaris longus to reposition the hand but achieved little if any success.
Madelung reported that the appearance of the deformity would not disappear with surgical treatment but that symptoms could be reduced greatly.
He recommended "wearing a custom made cover of stout leather, moulded around the shape of the wrist.
...Such a collar permits labourious occupations and prevents, nevertheless, all too exaggerated movements in the wrist."(l)
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References
1.
Madelung OW.
Die spontane subluxation de hand nach vorne.
Verh Dtsch Ges Chir 1878;7:259-276.
2.
Flatt AE.
The congenital hand anomalies.
St. Louis: The C.V. Mosby Co., 1977;50.
3.
Harley BI, Carter PR, Ezaki M.
Volar surgical correction of Madelung's deformity.
Tech Hand Upper Extremity Surg 2002;6:30-35.
4.
Canale ST.
Madelung deformity.
In: Campbell's operative orthopedics.
10th ed. St. Louis: Mosby, 2002:76.
5.
Nielsen IB.
Madelung's deformity.
A follow-up study of 26 cases and a review of the literature.
Acta Orthop Scand 1977;48:379-384.
6.
Bruno RI, Blank IE, Ruby LK, Cassidy C, Cohen G, Berg- field TG.
Treatment of Madelung's deformity in adults by ulna reduction osteotomy.
J Hand Surg 2003;28A:421-426.
7.
Paus B.
Madelung's deformity: 27 cases in 6 generations.
Oslo: Kommisjon Hos Iacob Dybwad, 1941:8.
8.
Lamb D.
Madelung deformity.
J Hand Surg 1988;13B:3-4.
9.
Ezaki M.
Madelung's deformity.
In: GreenDP, Hotchkiss RN, Pederson WC.
Green's operative hand surgery.
4th ed. Philadelphia: Churchil1 Livingstone, 1999:528-533.
10.
Schmidt-Rohlfing B, Schwobel B, Pauschert R, Niethard FU.
Madelung deformity: clinical features, therapy, and results.
J Pediatr Orthop B 2001;10:344-348.
11.
Vickers D, Nielsen G.
Madelung's deformity: a surgical prophylaxis (physiolysis) during the late growth period by resection of the dyschondrosteosis lesion.
J Hand Surg 1992; 17B:401-407.
12.
Salon A, Serra M, Pouliquen IC.
Long-term fo1low-up of surgical correction of Madelung's deformity with conservation of the distal radioulnar joint in teenagers.
J Hand Surg 2000;25B:22-25.
13.
Dupuytren G.
Lecon Orale de Clinique Chirurgicale Faites a L'Hotel-Dieu de Paris.
1834;4:197.
14.
Mostofi SB.
Who's who in orthopedics.
London: Springer, 2005;89-92, 214, 217-219.
15.
Malgaigne I.
Traite des Fractures et des Luxations.
Paris 1855;2:259-276.
16.
Nelaton A.
Luxations du Poignet.
Elements de Pathologie Chirurgicale 1847;2.
17.
Rang M.
Anthology of Orthopaedics.
Edinburgh: E & S Livingstone Ltd, 1966:36-37.
18.
Brooks TJ.
Madelung deformity in a collegiate gymnast: a case report.
J Athl Train 2001;36:170-173.
19.
Vender MI, Watson HK.
Acquired Madelung deformity in a gymnast.
J Hand Surg 1988;13A:19-21.
20.
Leri A, Weill J.
A congenital and symmetrical syndrome in osseous development: dychondrosteosa.
Communications and Archives of the Medical Society of Paris Hospitals 1929;35:1491-1494.
21.
Houshian S, Jorgsholm P, Friis M, Schroder H, Weeth R.
Madelung deformity treated with Ilizarov technique: a report of two cases.
J Hand Surg 2000;25B:396-399.
