(1)
Groningen, The Netherlands
Wrist Misalignment
Crooked Wrist
Complaint: the wrist has an abnormal position.
Assessment: there is ulnar deviation of the hand and a curvature in the radius. There are also multiple swellings of the skeleton elsewhere.
Diagnosis: osteochondroma (exostosis).
Explanatory note: osteochondroma. In 60 % of patients with hereditary multiple osteochondromata there are osteo-chondromata around the wrist (Fig. 7.1). Osteochondromata localized in the distal part of the ulna cause a shortening of the ulna and a curvature in the radius with an ulna orientated distal radial growth plate, resulting in ulnar deviation of the hand and ulnar shifting of the carpus.
Fig. 7.1
An osteochondroma localized in the distal part of the ulna may cause shortening of the ulna and ulnar deviation of the hand
Supplementary assessment: anteroposterior and lateral X-rays of the wrist.
Primary care treatment: none.
When to refer: if there are functional problems.
Secondary care treatment: osteochondroma. Treating this is controversial. As a rule, patients aren’t bothered much by this deformation. Some orthopedic surgeons advise excision of the osteochondromata and operative lengthening of the ulna. An objection to this is that recurrences are frequent so that ulnar lengthening has to be redone. In addition, mobility of the wrist is not improved.
Wrist Swelling
Hard Swelling on the Back of the Wrist
Complaint: there is a slow onset hard swelling on the back of the wrist.
Assessment: there is a swelling on the dorsoulnar side of the wrist.
Differential diagnosis:
Madelung deformity
congenital type
acquired type
Explanatory note: Madelung deformity. Madelung deformity is a growth disorder of the distal radial growth plate (Fig. 7.2). This growth disorder is usually congenital, but can also be caused by a trauma or infection.
Fig. 7.2
(a) Madelung deformity. In a congenital Madelung deformity there is disturbed growth around the anteroulnar part of the distal radial growth plate. This causes continued growth in the posteroradial part of the distal part of the radius, resulting in palmar flexion and ulnar deviation. (b) The ulna is relatively too long and the distal part is posteriorly subluxated
Congenital type
The congenital anomaly is twice as common bilaterally as unilaterally, and is four times more common in boys than in girls. This deformity is also seen in certain types of dwarfism (Léri-Weill disease1). The anomaly is seldom noticed before the age of 10, and it increases in severity from this age until growth stops. A congenital Madelung deformity presents an abnormal 5–7 mm thick fibrous structure (known as the Vicker ligament) (Fig. 7.3), that runs from the antero-ulnar part of the distal radial metaphysis to the lunatum and the triangular fibrocartilaginous complex (TFCC). The TFCC consists of an articular disc between the ulna and carpus and the ligaments between the ulnar styloid process and the ulnar carpal bones (lunate, triquetrum, hamate and the basis of the fifth metacarpal). There is disturbed growth around the antero-ulnar part of the distal radial growth plate. This causes continued growth of the posteroradial part of the distal part of the radius, resulting in palmar flexion and ulnar deviation. The ulna becomes relatively too long and this causes a posterior subluxation of the distal part, which explains the swelling on the postero-ulnar side of the wrist. Assessment shows that the wrist is much broader than normal. Patients consult a physician primarily for cosmetic reasons but later on because of pain and reduced dorsal extension.
Fig. 7.3
Vicker ligament in Madelung deformity. Vicker ligament is an abnormal 5–7 mm-thick fibrous structure that runs from the antero-ulnar part of the distal radial metaphysis to the lunate and the triangular fibrocartilaginous complex (TFCC)
Acquired type
The deformity resulting from a trauma or infection is caused by an osseous bridge around the ulnar part of the epiphysis in the distal part of the radius.
Supplementary assessment: anteroposterior and lateral X-rays of the wrist joint.
Primary care treatment: there tend to be few or no problems and treatment isn’t usually necessary.
When to refer: when there are functional problems or if there is pain.
Secondary care treatment: Madelung deformity. Operative removal of the osseous bridge on the ulnar side in the distal part of the distal radial epiphyseal growth plate caused by a trauma or infection tends to produce disappointing results. Firstly, this is because removal of the peripheral bony bridge is not very successful. Secondly, children are almost grown up when the anomaly is recognized, so that after removal of the bony bridge correction due to growth can no longer be expected. It is better to do a correction osteotomy in the distal part of the radius and an osteotomy to shorten the ulna. The Vicker ligament must also be removed in the congenital type.
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