MADELUNG'S DEFORMITY JOSEPH I. ANTON, M.D., GEORGE B. REITZ, M.D. AND MILTON B. SPIEGEL, M.D. BROOKLYN, N. Y. FROM THE SURGICAL SERVICE OF CUMBERLAND HOSPITAL, MERRILL N. FOOTE, M.D., DIRECTOR, BROOKLYN, N. Y MADELUNG'S deformity may be described as an idiopathic, progressive curvature of the radius due to a dyschondroplasia of the inferior radial epiphy- sis, resulting in a deformity of the wrist, giving it the appearance of an anterior (or, more rarely, a posterior) subluxation of the hand. Several earlier authors, including Madelung himself, have accredited Dupuytren with the first reference to this condition, while others have given it the double patronym of "Dupuytren-Madelung," but Stetten,22' who has carefully exam- ined Dupuytren's right to this distinction, finds that it cannot be substantiated. Dupuytren's report,73 in I834, is based on a quotation taken, by his own admission, from Begin,11 who, in I825, noted among adult male workers, not the typical spontaneous deformity, but a true forward dislocation of the wrist as a result of occupation. Other similar reports of a vague213 or secondary static deformity130 appeared soon after. Probably the first description of the true deformity was that by Mal- gaigne,138 in I855, while in I875 Jean 115 reported the first definite anatomic dissection. But the credit for first presenting a clear picture of it as a dis- tinct clinical entity reverts to Madelung,135 WhO, in I878, before the Seventh Congress of German Surgeons, described the condition as a disturbance of growth in the joints, analogous to pes valgus, genu varum and scoliosis, and regarded it as a subluxation of the wrist joint. It remained for Duplay,7' in i885, to point out that the deformity was a result of volar bowing of the distal end of the radius. Practically all that has been written on this subject has appeared in the French, German and Italian literature, and it was this fact, together with the paucity and meagerness of references to the subject in the various text- books, that prompted Stetten,221 in I909, to describe, in American literature, a case of the deformity which he had previously reported220 abroad, and at the same time presented a complete review of the literature relating to it. Although he definitely mentions several previously reported cases in America, he has been misrepresented by subsequent authors as having reported the first case from this country. At the present time one finds the reports of cases of this condition in a deplorable state. They are inadequate, often vague and unconvincing, while references are meager and all too frequently incorrect. Instead of being content with a case report, a quasi review of the Submitted for publication April 22, I938. 411 ANTON, REITZ AND SPIEGEL AnnalsofSurgery _~~~~~~~~~~~~~~~Spebr literature has been presented which merely serves to perpetuate the inaccura- cies of previous writers. Pooley,176 in i88o, evidently totally unaware of Madelung's report, de- scri.bed the first authentic case in American literature. Kieffer,120 in I902, briefly described another; Peckham,165 in I907, poorly presented a ques- tionable case in a girl, age 14. Brinsmade,28 in I909, reported the fourth case; Stetten221 wrote his incomparable article in I909; a few months later Peckham and Hammond,166 in a presentation of interesting cases from their clinic, reported two cases (Nos. 3 and 4) as examples of Madelung's deformity. In one of these no evidence or description warranting a definite diagnosis of the genuine deformity is given, although the other case (No. 3) is an ex- cellent example of the rare reverse type of the deformity. Stokes223 added two more American cases in I9I0, while in I9II, Jones'16 briefly described another case, and Taylor225 reported two cases in 19I2. In I914, Adler- briefly described a case which he called Madelung's deformity, while in I915, Parkes164 reported a case upon which he had operated with excellent results. In I9I6, Earl74 gave a good presentation of an early case of the deformity. Despite the availability of these reports in American literature, or at least their mention in Stetten's article, Brown,31 in 1924, reported his case as "the fourth case reported in America," while in the same year Levyn,132 realizing Brown's mistake, as he thought, wrote a "report of two cases con- stituting the fifth and sixth American cases," when in truth they were really the sixteenth and seventeenth. Also in I924, Moore154 reported two cases upon which he had operated, while in 1936, Claiborne43 reported a case. Emboldened by a thorough, methodical and exact survey of the related American literature, we feel we are correct in reporting the case herein cited as the twenty-first from this country. Two reports162 238 have not been included in this series since they obviously do not fall into the category of a true Madelung's deformity, presenting, as they both do, lesions of the ulna and not of the radius. Comprehensive reviews on this subject have appeared from time to time. In I903, Abadiel compiled a bibliography reporting 4I known cases of the deformity which he had succeeded in collecting. Gasne95 reviewed the subject in I906, but did not add any new cases. In I907, Estor77 published a total of 85 cases. Stetten221 collected, and gave brief summaries of 62 cases up to I908. In I908, Siegrist212 tabulated 58 cases, and Franke,87 only 56. In I909, Marsan140 listed go cases; in I9iI, Ramos185 listed 69 cases, while in I9I3, Melchior,152 after reviewing the subject, accepted only 75 cases, while in I933, Salisachs203 reported a total of 133' known cases The discrepancy in these figures is obvious, and is due to the considerable difference of individual opinion as to what constitutes a true instance of this deformity and on what evidence it is to be accepted. Although only five cases reported by Madelung are specific enough for acceptance, he claims to have seen I2, and he is sometimes credited with that number. In the dis- cussion of Madelung's paper,135 Czerny claimed to have seen two cases, 412 Volume108 MADELUNG'S DEFORMITY Number3 Hirschberg two cases, and similar cases were claimed to have been noted by Langenbeck, but Abadiel discards their claims, being unable- to find pub- lished reports of their observations. In the discussion of Gangolphe's paper,92 Berard'5 described a case of his own, which Stetten is inclined to accept as genuine, but which we have discarded as being too indefinite for acceptance. After describing a case occurring in mother and daughter, Guepin104 reports a similar deformity in I4 other members of the family, while Fere83 claims to have seen 25 cases in male epileptics. We are rather reluctant to embody these figures into our own statistics. We have found, as Stetten also remarks, considerable diffi- culty in knowing just which cases one should incorporate. In our own tabu- lation, we have tried to follow Stetten's criteria in rigidly rejecting all cases where: (i) There is a reasonable doubt as to the actual existence of a typical Madelung's deformity, and a probability that the condition was some other pathologic lesion. (2) The deformity was of such a slight degree that it could scarcely be considered abnormal. (3) The description was too vague or the reference too indefinite to justify inclusion. Also tending to upset an accurate statistical compilation is the occasional report of the same case by two men, as it occurs in the articles by Weber235 and Busch,35 and Muller'55 and Franke.87 Stetten himself has reported the same case in two journals,220' 221 while it has been a common practice for several of the authors to rearrange their primary case report in subsequent articles. In view of the foregoing, we have attempted to eliminate these inaccura- cies from the literature, and have compiled a chart tabulating 17I cases which we have succeeded in collecting. We cannot agree with Claiborne43 in assuming that with the increasing number of examinations which are resulting from the Workmen's Compen- sation Act, and with the wider use of roentgenologic examinations in trau- matic surgery, there will be more observations and reports of this condition, since the type of patient presenting a true Madelung's deformity does not come from either of these two groups. We do believe, however, that the condition is not so rare as the literature would seem to indicate, since it is not frequently recognized, especially without the aid of the roentgenologist. Case Report.-Hosp. No. 69356: M. D., female, age i8, was admitted to the Cumberland Hospital, January 3I, i938, to the service of Dr. G. B. Reitz, complaining of pain in, and deformity of, both wrists during the past two years. She was born April I, I920, in the United States, and no history was obtainable of any birth injury having occurred. She had had measles, whooping cough and diphtheria. At age 9, she was struck by an automobile, but there was no history or evidence of any local injury to the wrists. She had not engaged in any particular occupation which might account for her deformity. Her mother, age 47, three sisters and two brothers are all living and well. Her father died of pneumonia at age 47. There were no deformities or any 413 ;.......e.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. ...... .... ...,. ANTON, REITZ AND SPIEGEL AnnalsofSurgery September, 1938 indication of syphilis or rickets in either parent or' hi Vh -of her five brothers and sisters. Physical Examinationt revealed a well developed, well nourished girl, i6o cm. tall, weighing 5o kg. Temperature, 99.2°F.; pulse, 84; respirations, i6; blood pressure, i3p/65. The visible mucous membranes are of good color and the teeth are in good condition. FIG. I.-(A) Lateral view showing the characteristic bayonet-shaped deformity and the shortening in the length of both forearms. (B) Anteroposterior view showing the prominence of the head of the ulna at the back of the wrist, and the ulnar deviation of the hand. The organs of special sense, and the thoracic and abdominal viscera are all apparently normal, and there are no sensory, trophic or vasomotor disturbances. There are no frontal or parietal bosses, the thorax is well formed and there is no scoliosis, rachitic rosary or Harrison's groove. The hips and knees are normal and the tibiae are perfectly straight. There is no broadening of the epiphyses. One is immediately struck by a curious bilateral deformity at both wrists (Fig. I A 414 TABULATION OF ANAL4YSt OF RELEVANT DATA OF 171 CASES OF TRUE MADELUJNG'S DEFORMITY TABULATION OP ANALYSES OF RELEVANT DATA OF 17I CASES OF TRUE MADELUNG'S DEFORMITY (Coontinued) - . .. . . . . . . _ t93S ness dcarpus:Ditplacodastiorly. Roent nterior of e radl@=th4eph I52. Salizchs I6 Student Idancy - _ BilaXrS, htwnorto Xion $uUsation of the inferior radio-ulna ISl. FiCk und PaS ZI Semant I9 No richX - Xght Work produ MarEd Smitation of Mna: Pmminence of the distS end. - _ , * _ . _ IZ5. Debe 13H Weaver; plUJ IX Hard, exhausting Luetic Bilateral Intt in Extemion diminishi Swiliw at ti i the t with ap- nsao¢imwaall.dSfuopritnaRtoiaotnge"nPodgtrio" of the bme . . ,- IxII6776r809.... RASBBIspouu9iscIIIrrset3h9999rrgo6e3333ooen7r778wlw,ssReitz,and MI^MFIII31..874.3*dj jWSucanhrioeoorhl--obculoesyrekamnadn II9S86 NHNaSnopgioohrettairbZisirycntleaaocdeurrutytsi-oogtfhaotttwsrarrangiussetmtgsaa;.t --- BmRBRiaiiillrggaalhhttcetteerradall,onmroigrhet vw"PPrraGaimirsu,tnowsiwonairbnsnode-gta"khfnwtereperiaswsionsrlicn eAcEdclF4tttLlt3slauBad0iiliis.x0talxcus°ooo°me°letttc.en,nnisflnetinhomotyisnlLioeii°eAonoiesiog.nn.Fdnobimlnc,fztv:oniisrtdocueAngRIsteolru_:t°iale.Oidnny.bsdc58mef°oldtle0i0otoRre.d°tus°Pra.m.n.E.e,Ndr,Mad:eoaSA.cAuPlLotnnbdlcmR.auae°dd:dvti:st.(agupui1ipaiSodoc$oeoboRLeo°--°)--Zwn.e.n.n etIUFlUjvfItwiotmtbHnmhRMeJhelaountoiheiieaahaolarectrsrnadddontdrfnneetennukabaa.aaehtatloonrrotclld:a:lr.:eartmdiRoimrituHam,LefogkbarzPzs.omnaedoiHnorbaademdtagt'nadiawaaottaiwnels.'ohocdedjiiwtnuueor£sreR:leooro8dWRrmrg.actac&nntcaf:ruscrRi}ertat""hdaootalttl:nSeanixoedeLfaisedrhDnoomdpditaloufbe.weigrinuiuiaoaonwlsreusn6otstdf:rnfaige.od:nle:phteotosfirrtBohtnlcedtataoMmhreDaoaaCh.clon8nttiaaef;thpcwaeUhhldbnsrhreaeotrreeiael"peor£odkapRhcdordcdnrlnaaanomndowfjuaetaldcatfoddwoeramvhncctbiireabtvrceeeahWlagroo:aatrwf:trdde:iowtnmtnsHtopioassreherueetuafrBhearbtsael"srlDtdweotntediae.deieyaanuhthc*bilbdstrapro.oseuu"Rao"psndhosersHibw:PolstcwP.ifpy,dlouoaeahelyetyckscrrlnrvsncbruatnrhoiNlneoio£eudhoraontaersiycatsdlzfie;-,tItvpDhnaariecbueslrlscoeestshiaoosocnnefesddnrtotodrfhpiaegtlliheatescaorilfiaannitnimihoae-8eflrtEhoRosOTeemcptosayeiotdr.sm..ariyetoPLtinliuoarnnosneftaaestrrfhooaeresbntouceovlasonesttaee-rw- FmteCuineoonirnncnrttgneiocortnmiaaolnl.goNiomodp.srhoMovoret--. TABULATION OF ANALYSES OF RELEVANT DATA OF 17t CASES OF TRUE MADELUNG'S DEFORMITY (Canhru6X) N Authdor and Occupation AOgneseatt R Casusli Heredity Unilaterallor WristJoint wxamination OtherAbnormglities Treatment CourseorResult Symptoms Function XhI. Lewn 56 Houede IZ Nohis*oftra MotherofpatientS Bi1 No Sn, St w Bstension limited. ffio.mngofiiusandinatthslight Glandular therapy 924 F. orridrets low arefatiguedmoreeaF Flexionincreued bowingofbothbones.Pronounced back- (thyroid, pituitary ily thannoal ward didocation of ul Escavated andantuitnn) wedgaped appoanmee of articular surfacosofradius dulaa. Roentgeno- gram tZ2. LevIy8n Student I} Noricketsortraa. Dawitsofabove BiNterd No . S*ht r- Extension limited. Bowingofiusnot60rkedasabove. Glandular therapy Increase in length of I924 F. Playedpianoalot tionproducesfatigue Flesionincreaset Escavated and wedgeZ6haped articular (thyroid, pituitary ulna. No change in surfaces. Roentgenograxn andantuitnn) deformity IZ3. Moore I6 Typist; plays I4 Nohistoryoftrauma - Left Panin Extension limited. fthand.>placifod.:Head Cuneiformosteotomy. Deformity corrected; I924 F. piano orwork ionunyf very pxminent. Rdu:bserfourffi Plaster encasement, extension increased- bowedforward. Roztgenogram inestension flexionnownormal tw4. Moore I5 - I3 Patientbowedagreat - Left Painh Extension limited. Ulna:MarlxdbacZnrardprojectionoftS Resectionofthehead Good I924 M. deal PSion unusually free head. Radius: Somefonrardcurrature of the ulna. &tured Huld: Deviated to tlr ddE. Roent tower end ofulna to Benogram carpus Massage, active and t924 F. housework Work. Notraumaor xrristsd foreaxos, andpainful.Supination parentantedordisplacetoftheEnd passive motion. Os- Ackets. Positive Was- argrawtodWmotion. and adauction do- Radius:Antenorcurviture,withatrophj teotomy considered serma5nrneal_ofmsts od.Pronationand oftheulsideoftheepiPhns.Infenor andwillbeperformed &sionnormal ulnararticulationlusatedfromradiusand atpsopertime CrpU8. Roentgenogram I26. Garrido-Lestache I3 Field-hand II - - Right Noseswep.Wealc- Estension limited. ApparentanteriorLsplacementofhand. Immobilization and I925 M. nessdXhtlrrist Plosionautod Swilingofulnarheadatbwkofwrut. rest Radius: Anterior bowt. Roentgenoe m rs7. Llardoand I4 - I3 _ _Bilateral, espe- Fatig = the right Esion, adduction, Carpus:Apparentanteriorlutation.Ulna: Gallardo P. ciallytheright wristi andsupinationlimitod Prommenceofthoheadatthebaclcoftho I925 onrightsido st. hdii: Antonor bo. t- genogram IZ8. Merlini 25 Housework II Nohistoryoftrauma. - Bilateral Cont"ous, saguo Extonsion md aMuc- Wnao: Marked pnminenx of heds. I925 F. Noendenceofrickets painisXwrdur- tion xduxd. Prona- Po: Shortened. Radii: Anterior ingcoofdisease tionandsupinationnot andlateral bowingofshafts. Dehiscence modified. P1exion and of the inferior radio-ulnar articulation. adduction more thanf Hand and carpus: Displaced anteriorly, normalin normal relation to tho arfidoulatislg surfaceoftheradius. Roentgenogram I7 Stsg.eMasssinirvant7 Noevidenceofrickets. - Bilateral esne- painoFhrdworkereZ Leftsidenorxnal.Right: Ulsa:promsnenceofthehead.Foreas: 1925 F. daUyth;nght lievedbyrellt tAibodnUrcti°tn ddExdtUen bMOaFuxgd Rho°eritgengOZ|sRdius Anterior slonzero I30. DeBernardi I0 - 4 Nohistoryoftrauma - Left Pain*0n6etandon P1ezcion inczeased. 13x- Leftforearmshortened,deformityatthe - Course: I8mos. Z5 F. palp*u tensionlimited baclcofthewrist. Lusationofthieinferior hi radio-ulnarjoint.EniDhysisoftheradius turned anteriorly. Hand displaceid for- -ward,innormalrelationtothearticulat- angsurfaceoftheradius. Roentgenogram 8 &I3I.hDeBernoardi olgirl3 Notrauma. No evi-- Right Painip omet. Stab- Estensionn. Abduc- Swellingatthebackofthewnst.Radius. I925 F. denceofrickets bix*onmotion fionted Bowed anteriorly at the rerion of the ewiphysis. Hand: Di9placed anteriorly. Roentgenogram I7I32.J6Asapprentice I4 Hardwork Orphan no recollec- Bilateral, espe- Slight bin at onset Estension: R. 48° L. Hands:Bayonet-*apeddeformity.lilnae: Scoliosis and tenu - _ I926 M. blacksmith tionofamily ciallytheleft relseV<brwork 3p. Flesion: R. ;8°@ Prominenceoftheheads. Radius:Shorter valZum. Islgulnal L.8I°. Adduction:R:. thanulna, moremarlcedontheleftside. herma Xo° L.26°.Abduction: Roentgenogram R.I0°;L.s6°.Supqna- fonnormal r33. Catterina 33 Senrant Child-Bi-la_teral NoP;inthewrists Bstension limited. Radiu8: Marlced anterior and lateral I920 F. hood ; ionand adtuction vatureofthelowertErd, thmod- in-creased eratecurvature oftheuppertwo-thirds Ulna: Slightly bowed forward, heads pro"iment atbackofwnst. Hand: DisZ z placodforward. Roentgenogram I34. Pedrazzi I2 khoolarl 8 Notraa. PossiKe Mother and ynger Bilateral, espe- Painbn grasping, Extension difficult. SweNingatthebackoftheleftwnst.Ap- Patientquitesmatlin ncIk9e2t7Fs. sisterhavesimilarde- ciaNytheleft writlZ sewix. and Zexion e. Maked tantenordislocation oftheists. 8izeforherage formities hardarlc limitationofabduction Radii:Bowedanteriorb. Leftarmshort- >:fiandadduction ened. Roentgenogram Patientquitesmdlin - Pedaz * 15 - II Possiblerickets.Plays Sisterofabove Bilateral, espe- Moreorlencontinual Flexion easy. Bx- IJlna: StEloid,rrorninent on right liide sizefor}^era8e 35. r zK F l)iano. Notraurna cialbthenght Pain dkuacstiioonnadnifdfiacubldtu.ctAido-n RHaadnidu:s:Displacedfloakrrwaalrldy.Raonedntagnetneorgiorralry 6. Foschilu 20 Shoernaker ll N°h;Storfyo.fkraturna - Biilaterhl,er Painonworlcing - - rkedinthelowertbird. "Pork". hand deformity,mnthantenordisplacementof thehand. Roentgenogram . Tollas 16 _ 11 _ _ Bifateral, right Patfromonset,with Bxtension: R. 45°; L. Ulna: Prominenceoftheheads. Carpus 1927 F morethan1eft P,duparloSienscsrieoanseofdutrh-e fpfLieo°.9°atFil°enxninobnO:ortRm.hd89.0i°ds; ARDopeanrtegnetnoganrtaemrior luxation. Bilaterai . pnationdecrea edab duction4s°;addu; zo° I38. Roederer so Domestic Puberty - - Bilateral Weakness,cl_; Estsionslightlylim- Ulna: Abnormal swelling of the head Paticnt verysmallin Deformityreducedby Relief of pain for 3 sgs8 r. serant unabletodoharderork ited. P1exionandpro- above the wnst reducible on pressure. sse pressure, and held in mos. nationnonl Sublusationoftleulnafromtliaradius placebywristband ,,Zd, .:St.at s3I39.BPerteoleattisant 18-I9 Hard work. No evi- - Bilateral, espe- Pun on mot;ion znd Limitationofatewlsion RJlna: Bilateral prominence ofthehead - Operativeinterference Course: 4 yrs. De- g28 F@ dencesofrickets ciallytheright Sngeofweaths and abduction. In- espedallyonthenght. Radii:Amoderate notdeemedjustifiable formity still present, creax of flexion and lateral and snterior curvature, bringing r painless zdduction thearticularsurfacesdownandinrvard. Hands:DiEplacedfonvard t40. F61is I6 Handworker ISH Nohistoryoftrauma. - Bilatera} P"ninboth" Extendon so°, fon BayonetOaXddeformityof.Wna: Esostosis of both - - I928 F. Norickets 80°90°supinationde- Prominenceoftheheads. Radii: Marked ulnaenearepiphylL creased;adductionless antenor bog the ulnarthirdofthe lsne lower epiphysis is missing. Roontgeno- gram 14I. &hnek I8 - I0 Nohistoryoftrauma. - Right Righthandwzlc.No Righthand:Estention Rightforearmshorterthanleft. Carpus: = Smallinstature Triangularosteotomy Threemos.later:Good I928 M. Nonckets n andabductioni Subluoted anXriorly. Radius: S cm. of the radius. Resec- functionandallmove- shorterthanulna. Roentgenogram tionoftheulnarhead. mentspresent Plaster encasement, withhandficedines- tension I42. Schnek 36 _ Youth Fractureofradiusat - Bilat PAnoningai on 85°i eion i:Anteriorbowing.Forearms:Short- -Osteotomyandresec- 1928 F. age2;badly et 20°;abductlon25°;ad- ened. Carpas:Subluxated,moremarked [ tionasabove ductionnone onnght £5 .VidSalervant Infancy Hard work. No Mother, two sisters Bilateral No psin. Able todo ion80°o°esten- Ulna: Prominence ofthe head. Disloca- Bilateral, pulmonary - - I929 B. trau andanihavesi- hadwork sion 5° abduction tionoftheinferiorradio-ulnarjoint.Hand tuberculosis lardeformities Limite aSlductionaug- and carpus: Apparent anterior displace- mented.Pronationand ment. Radius: Lower fourth is curved ! suationnormal laterallyandanteriorly. Roentgenogram ;,o C.Voidal ok Irlfancy Nohistory Sisterofabove Bilateral Pain on exvgerated Estension4s°. Flexion Ulna: Head projects over tbe carpus. I9m2o9t.ionofwn 80°-go°. Abduction iw: Lower tid ced antsiorly. Iimitod. Adductionin- Hand and carpus: Displaced forsvard creasod.Pronationand in normal relationship to the radius. supinationnormal Roentgenogram .F1a2zio14_ Nohistorsoftrauma.- Bilateral, espe- P inatonset Activemotionpresont RstEus: SUght anterior curvatllre atthe Slightofstature Oblique linear oste- "Cured" I930 F. Noriclcets ciallythenght regionoftheepiphysis, andslightlateral Iotomy.Applicationof curvatureoftheshaft. Handandcarpus: : plasterencasement I bteriordisplacement. Roentgenogram t46.Roc7heretR0oudi-l24historyof trau-ma Bilateral Notroubleesoepton Hands held in fisod Ulnae: Prominence oftheheads, dueto I9h3a0rd.worlc pronation. Supination ltionfromtheinferiorendoftheradius. _ _ imoossible. Estesion Radius: Lateral bowingofthediaphysis dfiesionnormal and anterior bending at the epiphysis. .Hemiatrophyoftheepiphysisontheul ado. Roentgenogram __ _ s47. Cserey-Pechany I8 - I2 Irregular menses. No - Bilatera1 - - Dislocation of the inferior radio-ulnar * -Ovarian and gland- Courseceased.Roent- I930 F. sidencesofrickeX articiadons. Radii: Bowed anteriorly t ularhormonetherapy genogram "evidence" and laterally. Hemiatrophy of the inner for7mos. ofimprovementofthe half of the inferior radial epiphysis. deformity Roentgenogram I48.IGa8zzottiIroner(presser) I4 Notrauma.Nonckets.- Bilateral Slight pain onall Ezctension and abduow Radii:Bilateralanteriorandlateralbow- *-Oblique osteotomy Very good. Ten mos. X93I F. movements tion reduced. Prona- ing.Ulnae:Overridethecarpussuperiorly. (bilateral) and appll- later all movements tion and supination Hands:Displacedanteriorlyinnormalrv * cation of plaster en- presentanddeformity limited.Adductionand lationtoradius. Roentgenogram casement cured flexion increased over nonnal . Tancredi F. MensNirregular - Bilateral - &pination imbPd°ssti,!On hedXstAIntforurth. Ulrlae: Heads project ¢ Legs and arm8 are Transverseosteotomy Perfect result func- t short compared to and application of tionally and morpho- adduction and ?ronae dor8ally. Hands: Displaced anteriorly. trunlc plasterencasement logically tionlimited.Plenonill- Roentgenogram creased _ , t tSO._Viannax3--It BikiS Pain-first duging Abduction, adduction, Wrut: Bayonetx4>d deformity, vit Wh Spinabifidaoccultaof Transver&eosteotomy "Brilliant" I93I F. day,thencontinitous pronation and supina- prominence oftheulnarheads. Radiu: s: of the lower cewival withcorrectionofde- -tion limited. Esten- Antenor bowing, especially inthelowl er and upper thoracic formity, first right, _sion nil. Flesionin- third. Dislocationoftheinferiorradic o- vertebrae thenleft crssed uluararticulation. Roentgenogram r- - _ I93I . onleft7) gdfatlgue stion and flX. pus:Antenorsublation.Raius:Marke d Abductionnormal sateralandslightanteriorbowing.Roent t- genogram Lr Hypemsiosis ofulrlar Immobilization in 1933 M czallytherunt tErdolrsedius iXoiad h&s:AuRsiorc=-ture. Ulna : epiphysis splint s0I53S3alisad-hs Idancy Hardtorkfor4to S Fatherhmsimilardv BiNteral, .e NodscoSoX Exteon, protion, Ulnae:Prominennofheads. Radii:Lat t- Kyphosis - _ I933 F. yrs. formlter callythengnt ndsup,inationlimsted. eralcurvature Abductwn amposable. Plenonesaggeratod ts4. Salzi9s3a3chs Ms5. Wribr - _ _ BciilaatlelryalX,riegnt Nopain lZdiiems:oixrttseedn.sCilooinnmtirtrsalcitguohrttehloeyfr pHbloawsniednnsge:,ntXm.posaRtraedminaitf:lcrAenndatreikrneitotrheanultleodrwieolrratheadirllafl -1t. teCthyarslotusigychsotauertmeatshenostkeeld- movemenss oentgzogram I55. Kun I4 - I3 Historyofestremeef- - Bilateral espe- Paininbothwmsts Extension andsupina- Ulnae: Posteriorlusationoftheinferio r Spina bifida occulta Plasterentap- Encasement removec fort,butF.I933 after onsetaallytheleft tiontion nlili.mitPedl.onAbdauuog-- eondn.'R^adili:lAnstertitohrhcpuanlrlabtunrde8.of'ejnPtZu r-o fAosyu.rmtphtoItuicmsbaacrra-. ptleinesdttowni.thOhsatnedoitnoemxy- bNeocaiumsperoofvpeamienn.t > llsat fiftla lumbar considered for later elltgetlO=lm vertebra. Pz walaus. date Gzuigum t56. Massabuau,Solas- - tI Noendenceofnclcets Historyo£similarde- 8ilateral Painotp¢olong.eduse Diminishedestension Ulna:ProminenceofEead.Radius:An - Nooperativeinterfer- Course:3yrs. etNichet F. formityinfather ofhandmmtmg andsupination tbog.Carplls:Apparentanterio r ence I934 lusatlon. Roentgenogram IS7. Kajon 7 - 7 Nohistoryoftrauma. - R4ght NopIa93i4nM. No ncketsBagxgteernastioodn. eaibtdluyctieosn- RBoiugrhitnfgo,rdearmw:Sihodretenrtohfanthloite.pRlapdhiyudss i: CeNcalrib decreased Roontgenogram . ChirS8Roclhe-retRoc5h7edr - - _ B^lateral, espe- Nop Nolimitationofmotion Ulaae Slightprominenceoftheheadsart Absenoe of the right _ - t934 r bood clallytheagat thebwlcofthewrists DidocationofUue caput humerus, and Lt maldevelooment of i. thetuberosity p1.* tg% I59. Canton 23 _ Child- Nohistoryoftrauma - Bilateral Nopain Handsheldinfixedpro- Ulna Prominenceoftheheadatthebad I935 M hood nation SBNtnatsi°nanmd llyhaendrtantenorlyatthedi exty lesonnonna s.oontgenogram I60. Barsoum I} _ II - - BilateS Pan X atremes of "Abo"tEtyof Hani d c. S2metncal wXr - _ _ z935 F. mo.tion. Weaknes of bothnutjoints ture, with thiclcening at the dist41 end 1. .oentpnogram I6I. Bederund25 Factoryworker I2-I3 Amenorrhea. No dv- Bilateral Pain h radiocarpal Limitationofostension Ulta: Strloid prominent and proiects Male conJEration. Suggests endocrine Heisi"mann F. relopmztofbreast Joint. ral wealc- dorsally. Radius:Bowedforward. Handi Deformitlr upper therapy - tibtaleih geam I62. Bederund 28 - I4 Oligomenorrhea - Bilateral - - Deformityofradiocupillioiltasaboure.t. _ _ _ Heann F. Roentgenogram I935 I63.Landiva6IryBarrendero St No earidenoeofricket-s Bilateral Nooordiscomfort Bstension qs°;flesion Radiw:AnteriorboUgvSeparationofE Rarefiea areasin left ITaguirre M. (?) t go°.Adductlon50°,ab raduFulnararticuladou.C:as:hItSiOIr lleum, pubis and I"X6 < dudionIO°. P>nation blum. ischialtuberosity ^< andsupination30° I64. Chienci I5 - I3>i - - Bilateral W_ Pronation, supination, IJlaae: Prorofh st baclc oSf - - _ I936 F. >:' Fdxisteaion limited l ristKtRadius.Allbriorcurvatureinthe Marloed limlgtation of phy.I^teralknriwo£thelowerfour* abduction; slight limi- Handmd:Dimplalforward but tadonofadduction inmltelSontothoarticularface at1hradius. Rootltgonogram I65. Chiezia I3 _ IZ Spontans - Bilateral ;* - htion and aMuo : Ai¢Engatffio*oif Curvature of both I936 F. r tion limited. .Adduoe {botduetoheadof1heulna.Radius:: tlblae tion slightly lamited. htedof ctmraturo at the metaphysis. Flenontogow Landandwrist: Ant¢riordisplacement. tnnormalrdationtotheradius. Roent : ogtam I66. Claiborneand I6 - 9 - - Bilateral, more Pala = wnst, espe- E.sten,don aDd *bduo IJInao: Heads pnmianat. Raelu: Bowed Euntz F. marlcedonright Cl*onmotion tlonEmitod a(.rllnyt.htChaerpcuo8n:vaAiptpye)ardsorsdailsllyo,caatnedd laantteer--. - _ rlorly. Roentgenogram I67. eRtouMdoilu,rguDeresvon, FI.4>; - IOH NNoosthiigsmtaotrayooffritcrkaeutms.a - Bilateral Pma.e6Wgeeailaclnleyssoonf Stuiponina7t0i°onf4l0e°n,opnrognoa°Z* Utlhnear:adLiuuxsaatinodncaorfptush.oiFnoferreiaorrmes:ndShforrotw1 Bilateral cubitus - - ^ talgu8 SUPPLEMENT totheArtieby I)BS. JOSEPH I2&N2X&GI~OflGR I321LZ and MILTON B. SPIEGEL, BwooxyN, N. Y. on MADELUNG'S DEFORMITY ATabulationof171 CaseReports Volume108 MADELUNG'S DEFORMITY Number3 and B), as if the hands had been dislocated anteriorly. There is also an obvious shortening of both forearms (left-eight and one-quarter inches long; right-eight and one-half inches long). A lateral view of the forearm and hand roughly resembles a bayonet (Fig. I A). There is a marked swelling at the back of the wrist which pal- pation determined as being the head of the ulna and which, apparently, overrode the carpus superiorly. Palpation of the lower end of the radius reveals a definite forward bowing with convexity on the dorsal surface, and a moderate lateral bowing with the concavity toward the ulna. This bowing has displaced the carpus and hand forward and to the ulnar side. The flexor tendons are sligbtly more prominent than usual. Measure- ments of the forearms show: Right Left Radius (from the head to the styloid process) ................... I8 cm. i8,2 cm. Ulna (from olecranon to styloid process) ....................... 20,4 cm. 22 cm. Hand andforearm (olecranon to tip fifth finger) ................. 32 cm. 33 cm. Circumference of wrist (at styloid process)....... I6 cm. i6 cm. .............. Thickness of wrist (at styloid process) ......................... 4 cm. 434 cm. Breadth of wrist (at styloid process)........... 5.8 cm. 6Y4 cm. ................ Humerus (from acromionto external condyle)...... 2934 cm. 2934 cm. ............ There is to be noted a decided shortening of the radius (from a normal of approxi- mately 22 cm.) of 4 cm. on the right, and 3¼ cm. on the left, and also a shortening of the ulna (from a normal of approximately 25 cm.) of 4 cm. on the right, and 3 cm. on the left. Motion is the same either active or passive, and is somewhat painful at the extremes. Mobility at the wrist is only slightly affected, and, although the deformity is clinically symmetrical, the right side is affected more than the left. The limit of motion from a horizontal plane is estimated as: Right Left Flexion go' 6o0 ................... Extension 300 400 ................. Adduction 30° 400 ................. Abduction 250 400 ................. Pronation and supination are within normal limits. During a short stay in the hospital for the purpose of observation, a laboratory study of the patient was carried out. Similar studies, partial or complete, have been madeby Beder,'0 Brown,8' Catterina,'0 Fazio,8' Siegrist,8 Stetten,m Tollas,w and Vianna.m The results obtained by these investigations indicate that this condition is not manifested by any deviation of the body's chemical or biologic processes. The data acquired in the present instance tend to confirm that impression. Laboratory Data.-Wassermann test negative. Basal metabolism minus four. Uranal- ysis: Color-yellow; I,OI5; alkaline; albumin, sugar, blood and bile, all absent. Micro- scopic examination essentially negative. Hematology: R.B.C., 5,030,000; Hb., go per cent; W.B.C., 8,950. Differential: polymorphonuclears, 65 per cent, lymphocytes, 33 per cent, transitionals, 2 per cent; platelets, 210,000; fragility, 0.45 to 0.27; sedimentation time, i8 Mm. in one hour and 20 minutes. Blood Chemistry Urea nitrogen........ m29.gmg. Totalcholesterol.. 105.3 mg. Sugar ............... 88.9 mg. Cholesterol ester... 65 per cent Albumin............. 9.3 mg. Calcium......... 10.5 mg. Globulin............. 2.2 mg. Phosphorus ...... 4.8 mg. Chlorides............ 625.0 mg. Icteric index. .......m.g3..8 van den Bergh: Direct and indirect-negative. 415 Co 0.~ 00.c.is cU) c.0 CU r -0 bOO.MCCU trb.o0 ,D 000 g-Y .0M UCCU o 0.0 U- I .CU .. 0*0..0U*) *o O= .0 0t clCu) ~. U) 0 0 CU CUU bC.0 COt- x9 U)0 .0 bo;Uk*C0 0C _tdUC bO. CU U). C CU h 416