Cubitus varus

1. Cubitus varus
Ponnilavan

2. Cubitus varus:
• A deformity of elbow resulting
in a decreased carrying angle
(˘so that with arm extended at
the side & palm facing
forward, deviation of forearm
towards midline of body)
CUBITUS - ELBOW(LATIN)
VARUS - Angle inward
• Common complication of
supracondylar fracture of
humerus

3. Carrying angle:
• Angle formed by long axis
of arm and long axis of
FA
• elbow -EXTENDED and
forearm - supinated
• Normal:
Male:5-10degree
Female :10-15degree
• Valgus : >15 degree
• Varus :<5-10 degree

5. Associated deformities of cubitus
varus:
• Internal rotation
• Extension of distal fragment
• Medial tilt
• Type of deformity - static

6. Progressive cubitus varus
deformity after SCH#
• Growth disturbance in distal humerus
especially overgrowth of lateral condyle
can occur & sometimes avascular necrosis
and delayed growth of trochlea with
relative overgrowth of normal lateral side
of distal humerus epiphysis

7. Causes:
• Most common cause is malunited supracondylar
humerus fracture
• Congenital
• Malunited intercondylar #
• Malunited medial condyle#
• Malunited lateral condyle#
• Trochlear osteonecrosis

8. Malunited SCH #
• H/o significant trauma
• Thickening and irregularity of medial and
lateral supracondylar ridge
• Maintained 3 point relationship
• Elbow - Hyperextension
• Internal rotation increased with restricted
external rotation of shoulder

9. Gun stock deformity:

10. Displacements:
• Medial tilt
• Medial displacement
• Internal rotation
• Posterior tilt
• Posterior
displacement
• Proximal migration

11. Measurements on Xray: AP view
A line drawn parallel to
longitudinal axis of
humeral shaft as well as
a bisecting line parallel
to lateral condyle
• Normal:64-81 degree

12. Metaphyseal-diaphyseal angle:
• Transverse line is drawn
through axis of diaphysis.
angle measured between
lateral portion of
metaphyseal line and
proximal portion of
diaphyseal line
• Normal = 90 degree
• >90 degree = varus
angulation
• <90 degree = valgus
angulation

13. Lateral Xray:
• Humeral ulnar wrist
angle: crescent sign
• Presence of this imply
angulation and
rotation

14. Treatment:
• Observation with expectant remodelling
• Hemi epiphysiodesis and growth alteration
• Corrective osteotomy

15. Observation with expectant
remodelling
• Not appropriate because although
hyperextension may remodel to some
degree in a young child, in an older child
remodelling occurs even in joint's plane of
motion.
• Hence, it is not recommended

16. Hemi epiphysiodesis and growth
alteration:
• It is used to prevent cubitus varus
deformity in a patient with medial growth
arrest and progressive deformity,rather
than correcting it.
• It has a no role in child with a normal
physis

17. Corrective osteotomy:
• Medial open wedge osteotomy
• Lateral closing wedge(French osteotomy)
• Oblique osteotomy
• Dome osteotomy
• Step cut osteotomy

18. Approaches:
• Medial, Lateral and posterior
• Lateral: Good exposure with less
dissection
• Posterior: Complex osteotomy require
extensive exposure

19. Pre requisites:
• Atleast 1 year following fracture
• Patient demanding surgery
• Calculation of wedge to be removed by
normal side X ray
• Wedge angle = varus + normal
physiological valgus

20. French osteotomy:
• French, in 1959 first described a lateral
wedge osteotomy held with screws and a
figure of eight wire and this remains the
most popular method of correction.
• Lateral closed wedge osteotomy

22. Modified french osteotomy:
• Modification of French's osteotomy
appears to fulfill these criteria
• Easy procedure ,minimal dissection, little
possibility of nerve damage

23. French osteotomy
• Posterior longitudinal
incision
• ulnar nerve explored
• medial periosteal
hinge
Modified french
osteotomy
• Posterolateral incision
• ulnar nerve not
explored
• medial periosteal and
bony hinge

24. Step cut osteotomy:
• A standard posterior approach used
• Incision extended proximally distal 3rd
upper arm to a distance of 1-2 cm beyon
tip of olecranon distally
• Mobilize ulnar nerve anteriorly
• Triceps muscle split longitudinally
• Circumferential subperiosteal disection
done

25. • Osteotomy was
performed by first making
a proximal, transverse cut
perpendicular to
anatomical axis of
humerus
• Cut was made in a
proximal-medial to distal-
lateral direction
• Next cut perpendicular to
angular correction cut
was made at its lateral
margin creating a step cut
in distal humeral fragment

26. Complications of osteotomy:
• Stiffness
• Nerve injury (radial and ulnar nerve)
• Recurrent deformity
• Non union
• Osteomyelitis
• Malunion

27. THANK YOU