[Illustration: FIG. 170.--Congenital absence of Left Radius and Tibia in a child æt. 8. (Mr. D. M. Greig's case.)] In _spastic paralysis_ the most pronounced deformity is flexion of the forearm and pronation and flexion of the hand (Fig. 166). Gradual extension at the wrist may be brought about by the use of a malleable splint, in which the angle is gradually increased, over a period of at least twelve months. Failing success by this method, operation may be had recourse to, and this consists in lengthening of tendons, and tendon transplantation. Tubby has devised an operation for converting the pronator radii teres into a supinator, and Robert Jones another in which the flexors of the carpus are made to take the place of the extensors. "These operations, combined if necessary with elongation of the flexors of the fingers, pave the way for diminution of the angle of flexion at the elbow, lessening of the pronator spasm, increase of the supinating power, reduction of the carpal flexion, and addition to the extensor power at the wrist" (Tubby and Jones). #Congenital Club-hand.#--This rare deformity corresponds to congenital club-foot, and probably arises in the same way. The hand and fingers are rigidly flexed to the ulnar or radial side, so that the patient is incapable of moving them. Treatment is carried out on the same lines as for club-foot. A deformity resembling this, _acquired club-hand_, is brought about when the growth of either of the bones of the forearm has been arrested as a result of disease or of traumatic separation of its lower epiphysis. The hand deviates to the side on which the growth has been arrested--_manus valga_ or _vara_. The treatment consists in resecting a portion of the longer bone. [Illustration: FIG. 171.--Club-hand, the result of imperfect development of radius. The thumb is absent. (Photograph lent by Sir George T. Beatson.)] #Madelung's Deformity of the Wrist.#--In 1878, Madelung called attention to a deformity also called sub-luxation of the hand, in which the lower articular surface of the radius is rotated so that it looks towards the palm; there is palmar displacement of the carpus, and the lower end of the ulna projects on the dorsum. The cause of the condition is obscure, but it is met with chiefly in young women with slack ligaments, whose laborious occupation or athletic pursuits subject the hand and wrist to long-continued or repeated strain. It is as frequently unilateral as bilateral and may recur in successive generations. There is a good deal of pain, the grasping power of the hand is impaired, and dorsiflexion is considerably restricted. The deformity disappears on forcible traction, but at once reappears when the traction is removed. A wristlet of poroplastic or leather extending from the mid-forearm to the knuckles is moulded to the limb in the corrected position, and is taken off at intervals for massage and exercises.