A 40-year-old woman attended the primary care clinic for pain in both wrists, loss of strength in the hands and paraesthesia in all fingers, with greater frequency and intensity in the right hand. The patient presented with chronic pain of five months' evolution with mechanical characteristics and progressive worsening, associated with deformity of the wrists. There had been no previous trauma to justify the presence of the aforementioned symptoms. She has no pathological history of interest. She is right-handed and works caring for the elderly.
Physical examination of both wrists revealed the presence of a deformity on the dorsal side at the level of the ulnar styloid, associated with ulnar deviation. In addition, there was increased sweating and reddening of the hands.
The joint balance (BA) of the wrists was symmetrical: dorsal flexion: 40o. Palmar flexion: 55o. Radial deviation: 20o. ulnar deviation: 30o. Supination: last degrees missing. Pronation: complete.
Pain on palpation at the level of the distal radiocarpal joint and discomfort on palpation of the radial head. He has a complete elbow AB. Muscle balance (BM) flexion-extension of the wrists is 4/5.
Moreover, the grip-fist-grip is complete. Opposition of the thumb is preserved. The metacarpo-phalangeal, proximal interphalangeal and distal interphalangeal joints are free. There is a negative median Tinnel's sign and a doubtful median Phalen's sign.
In view of the clinical findings described above, an anteroposterior and lateral radiograph of both wrists is requested.

After observing the presence of deformity on the X-ray, the patient was referred to the Traumatology outpatient department for assessment, where a diagnosis of Madelung deformity and bilateral distal ulnar dislocation was made.
Surgical treatment of carpal reconstruction was proposed, but the patient refused, so a referral was made to Rehabilitation. A bilateral nocturnal positional splint was prescribed, plus physiotherapy treatment (toning of intrinsic hand muscles and analgesic electrotherapy).

