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Congenital Hand
Published in J. Terrence Jose Jerome, Clinical Examination of the Hand, 2022
Madelung deformity is caused by growth disturbance in the palmar and ulnar portions of the physis. The Vickers ligament covers the palmar side of the wrist from the distal end of the pronator quadratus muscle [25]. A variety of osteotomies to correct the complex deformity based on plain radiographs have been reported [26,27]. Computed tomography imaging and recent computer software techniques are used to accurately evaluate the 3D deformity in the bones and to perform 3D corrective osteotomy using customized surgical guides [28,29].
Modified dome osteotomy and anterior locking plate fixation for distal radius variant of Madelung deformity: a retrospective study
Published in Journal of Plastic Surgery and Hand Surgery, 2022
Andrea Leti Acciaro, Lorenzo Garagnani, Mario Lando, Debora Lana, Silvana Sartini, Roberto Adani
All surgical procedures included the release of the Vickers ligament and a modified dome-shaped osteotomy of the distal radius (Figure 2), reversing the traditional osteotomy commonly proposed in literature [6,16–19]. Surgery was performed either under general anesthesia or in cases of compliant children, a brachial plexus block was performed and the children were entertained with a movie in the operating room [9]. The surgical access was on the radial side of the flexor carpi radialis tendon and the pronator quadratus muscle was incised radially, leaving a cuff for reattachment. During the dissection, the distal radioulnar joint (DRUJ) was preserved and the Vickers ligament was isolated and accurately released from the volar aspect of the distal radius to expose the radial metaphysis and shape the line of the osteotomy. The osteotomy was performed with the convexity distally on the proximal stump of the radius, and the concavity proximally on the distal stump. The line of the osteotomy was drawn proximal to the epiphysis and DRUJ to allow for accurate positioning of the plate without affecting the growth plate. The planned osteotomy line was marked and fenestrated with a K-wire, then the osteotomy was performed using the ultrasonic micro-vibration of a piezoelectric surgical saw, that allowed preservation of the dorsal periosteum and protection of the soft tissues (Figure 3). The reversed shape of the dome osteotomy was used to achieve a multiplanar correction of the distal radial fragment in extension and radial deviation. The proximally concave osteotomy of the distal fragment allows for an adequate dorsal translation of the radius and reduction of the DRUJ (Figure 3(A)). This technique also allows a simultaneous reverse wedge osteotomy, with the bone wedge harvested from the radial side of the distal radius then inserted into the ulnar side, augmenting the angular radial correction (Figure 3(B,C)). When required, the bone wedge was removed from the radial side [13,15,17] in order to avoid impingement with the radial diaphysis during translation-rotation of the distal radius, placed into the opening ulnar side or a block of hydroxyapatite was inserted in the defect in the opening ulnar side. Multiplanar correction and stabilization was mainly achieved without the addition of bone graft or hydroxyapatite support. At the beginning of the experience, cancellous bone allograft was also added into the osteotomy line to further enhance bone healing. The multiplanar correction of the distal radial fragment was secured with small volar locking plates and screws with angular stability (Figures 3(D) and 4). Depending on the size of the radial epiphysis, locking plates originally designed for metacarpal or dorsal wrist fractures fixation (smaller than the traditional volar plates) were used. Plates were also contoured according to the required radius correction and shape. The pronator quadratus was reattached onto the radius. According to the less severe deformity of the distal radius variant, no concomitant ulnar surgery was performed; ulnar epiphysiodesis in children with uncompleted growth or ulnar shorthening in almost completed bone growth should be considered at initial surgery with ulnar variance >5 mm or painful ulna within the carpal canal [14,15,20–23].