Deformities around elbow and management: Clinico-radiological evaluation, decision making and surgical options

1. DEFORMITIES
AROUND ELBOW
AND MANAGEMENT

2. INTRODUCTION
 Elbow is a complex anatomical and functional unit with a unique osseous,
soft tissue, and articular composition that also form an ingenious
functional entity.
 Disruption of this complex biological relationship, either through
posttraumatic or hereditary changes, can have a significant impact on the
functional system of the upper extremity, leading to pain, instability and
reduced range of motion.

3.  The elbow is a trochleogingylomoid joint composed of 2 primary motions:
1. The ulnohumeral articulation is hinged, ginglymoid.
2. The radiocapitellar articulation is radial, trochoid.

4. The distal humerus is composed of 2 articulations:
1. The trochlea, a spoolshaped articulation along the long axis of the distal
humerus
2. The capitellum, a hemispheric structure lateral to the trochlea.
The trochlea has a slight posterior tilt that prevents posterior translation by
relying on the coronoid buttress.
The proximal ulna contains 2 articulations, the greater and lesser sigmoid
notches.

5. HUMERO-ULNAR PART
 It is articulation between trochlea of humerus and trochlear notch of ulna
 The medial edge of trochlea is 6mm beyond the lateral edge
 Plane of the joint is 2cms distal to intercondylar line slopes downwards
and medially
 Two nonarticular depressions coronoid fossa and olecrenon fossa are
present in relation to this articulation
 Trochlear notch of ulna is reciprocally saddle shape and formed by the
articular surfaces of olecrenon and coronoid processes.

6. HUMERO-RADIAL PART
 Structurally it is a ball and socket type of joint.
 The ball is represented by capitulum of humerus and socket is by articular
surface of disc like head of the radius.
 In full flexion head of the radius lodges radial fossa above the capitulum

8. LIGAMENTS OF ELBOW JOINT
 Capsular ligament
 Ulnar collateral ligament or Medial ligament
 Radial collateral ligament or Lateral ligament

9. FIBROUS CAPSULE
 Fibrous capsule completely envelop the joint.
 It is attached to the lower end of humerus in a continuous line, which
excludes the two epicondyles but include three fossae. Cushions of extra-
synovial fat fill up the three fossae.
 Anterior joint capsule provides significant resistance to joint distraction, joint
hyperextension, and valgus stress

10. ULNAR COLLATERAL LIGAMENT
 UCL is triangular in shape and extends from medial epicondyle to medial margin of
trochlear notch. The ligament consists of three bands, Anterior Posterior and Inferior
 UCL is overlapped by Triceps ,FCU , FDS and Ulnar nerve.
 The UCL functions as a restraint to valgus and posteromedial rotatory instability. It
functions as the primary restraint to valgus stress, and the radial head provides a
secondary restraint.
 UCL-deficient elbows are most unstable in neutral rotation.

11. RADIAL COLLATERAL LIGAMENT
 RCL is triangular and extends from lateral epicondyle to annular ligament.
It is related to supinator and ECRB
 LCL complex functions as a unit to prevent posterolateral instability and
stabilize the radiohumeral, radioulnar, and ulnohumeral joints.
 Lateral collateral ligament deficient elbows are most unstable in supination

13. CUBITUS VARUS
 Cubitus varus is a triplanar deformity with components of
varus, hyperextension and internal rotation.
 Forearm deviated inwards with respect to arm at elbow with
resulting lateral angulation in full extension.
 Normal carrying angle ranges from 5° to 15°. An increasing
angle represents valgus alignment, and a decreasing angle
represents varus alignment.

14. CAUSES
 MC cause is malunited supracondylar humerus
fracture.
 INFECTIVE: medial growth plate damage.
 VASCULAR: osteonecrosis of trochlea
 TRAUMATIC: lateral condyle fracture
 NEOPLASTIC: secondary to exostosis in distal,
lateral humerus
 CONGENITAL : epiphyseal dysplasia

15. GRADED BY SEVERITY :
 Grade I - loss of the physiological valgus
angle
 Grade II - 0 to 10 degrees of varus
Grade III - 11 to 20 degrees
 Grade IV - more than 20 degrees

16. COMPLICATIONS
1. Pediatric cubitus varus has traditionally been considered a cosmetic problems with very few, if
any, functional deficits or pain.
2. Posterolateral rotatory instability (PLRI)
3. Ulnar neuropathy
4. Snapping triceps: It is a condition in which the distal portion of the triceps dislocates over the
medial epicondyle during flexion and extension of the elbow causing pain.
5. Progressive varus of the ulna and elbow joint malalignment.
6. Increased susceptibility to lateral condyle fractures

17. BIOMECHANICAL AXIS DISRUPTION
1. Varus malalignment of the upper extremity leads to medial
displacement of the mechanical axis of the upper extremity.
With repetitive varus forces on the elbow from activities of daily living,
such as pushing up from a sitting position, the lateral collateral
ligament complex experiences increased tensile forces and becomes
attenuated, leading to further medial displacement of the mechanical
axis.

18. 2. The triceps is displaced medially in cubitus varus, and this displaced
triceps force vector leads to an external rotation (supination) moment
arm on the ulna. Chronic medial triceps forces on the olecranon lead to
medial elongation of the olecranon and external rotation of the ulna,
which is the first stage of PLRI.

19.  Because of both of these biomechanical alterations, continued LUCL
attenuation and olecranon external rotation eventually leads to radial
head subluxation and eventually dislocation with frank PLRI.

20. MEASUREMENTS ON XRAYS: AP VIEW
 CARRYING ANGLE: The angle between the longitudinal axis of the
humerus shaft and a longitudinal drawn along the shaft of the ulna.
The axis of the humerus and ulna were determined by at least 2
central points of each bone.
 Normal carrying angle ranges from 5° to 15°. An increasing angle
represents valgus alignment, and a decreasing angle represents
varus alignment

22.  1. BAUMANN’S ANGLE : The angle is determined by drawing a line
straight down through the middle of the humeral shaft and then through the trochlea
and then drawing a line that is perpendicular to the humeral shaft line. Then a line is
made parallel, but running through the lateral condylar physis.
It should be compared to the other (non-injured elbow) as a comparison and a difference of
more than 5 degrees suggests a coronal plane deformity.

23. Baumann angle ranges from 64 degrees-81 degrees.

24. The Humerus-Elbow-Wrist angle
 The humerus-elbow-wrist angle is measured on anteroposterior
radiographs with full elbow extension (180°) and supination that accurately
reflected the outline of the upper extremities.
 To measure the humerus-elbow-wrist angle, we first drew two transverse
lines (one proximal and one distal) across the humerus that connected the
medial and lateral cortices and two lines (one proximal and one distal)
across the forearm that connected the medial cortex of the ulna and the
lateral cortex of the radius.

25.  We then drew a line connecting the midpoints of the two cross-humeral lines and
another connecting the midpoints of the two lines across the forearm. These lines were
extended until they intersected, and the angle of intersection was measured with a
goniometer.

26. The Metaphyseal-Diaphyseal angle
 The metaphyseal-diaphyseal angle is formed between the long axis of the humerus and
a line connecting the lateral and medial epicondyles.
 This ranges from 72 degrees to 95 degrees but is the least reliable estimate of the clinical
carrying angle

27. NORMAL- 90 DEGREE
MORE THAN NORMAL- VARUS DEFORMITY
LESS THAN NORMAL- VALGUS DEFORMITY

28. LATERAL VIEW: HUMEROTROCHLEAR
ANGLE
 Humerotrochlear angle corresponds to the angulation made between the
humeral shaft axis and the condyle axis at the lateral view radiograph.
 The corrective angle necessary to be applied along the sagittal plane is
obtained by measuring the humerotrochlear angle and comparing its value
with the reference value that is defined for the humerotrochlear angle, i.e.
the corrective angle will correspond to the difference between those two.

29.  40º is the reference value for humerotrochlear angle.

30. ROTATIONAL DEFORMITY
MEASUREMENT
 The extent of rotational deformity can be estimated by physical
examination.
 The examination performed by having the patient bend forward slightly
and setting the forearm behind the patient’s back with the elbow flexed
90° and the shoulder hyperextended maximally. The examiner held the
patient’s elbow as a fulcrum and placed the humerus in maximal internal
rotation by lifting the hand from the back.

31.  Whereas the hand of a person with a normal upper extremity cannot be
brought up from the back, the hand of a patient with an internal rotation
deformity can be lifted, forming an angle between the horizontal plane of
the midline of the forearm and the coronal plane of the back.
 This angle is considered to be the angle of internal rotation deformity of
the humerus

33. TREATMENT
 Cubitus varus deformity has no tendency for spontaneous correction
but it always has to be corrected.
Treatment options include:
(a) Observation with expectant remodelling
(b) Hemi epiphysiodesis and growth alteration
(c) Corrective Osteotomy

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

35. 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 no role in a child with a normal physis.

36. CORRECTIVE OSTEOTOMY
 Osteotomy is the only way to correct a cubitus varus
deformity with a high probability of success.
Options include:
 Medial open wedge osteotomy
 Lateral closing wedge osteotomy also known as
French osteotomy .
 Dome osteotomy .
 Step cut osteotomy
 Multiplanar osteotomy

37. Pre-requisites:
 1. Atleast 1 year following fracture (Bone remodeling and tissue equilibrium)
 2. Patient demanding surgery
 3. Calculation of wedge to be removed→Normal side
Xray→Wedge angle = Varus + Normal physiological Valgus
Currently, there is no surgical gold standard for the correction of cubitus varus.

39. CORA: CENTER OF ROTATION OF
ANGULATION
 The intersection of the proximal axis and distal axis of a deformed bone is
called the CORA
 It is the point about which a deformity may be rotated to achieve
correction.
 The angle formed by the two axes at the CORA is a measure of angular
deformity in that plane.

40.  The point where the humero-ulnar mid diaphyseal line
intersect is the CORA of the deformity.
Importance of CORA : It indicates where an axis of rotation,
named angulation correction axis or ACA should be placed

41. IMPORTANCE OF CORA
 If CORA lies at the point of obvious deformity in the bone and the joint
orientations are normal, the deformity is uniapical (in the respective plane).
 If CORA lies outside the point of obvious deformity or either joint
orientation is abnormal, either a second CORA exists in that plane and the
deformity is multi-apical or a translational deformity exists in that plane.

42.  When the CORA lies outside the boundaries of the involved bone, a multi-
apical deformity is likely to be present.
BISECTOR: The bisector is a line that passes through the CORA and bisects the
angle formed by the proximal and distal axes. Angular correction along the
bisector results in complete deformity correction without the introduction of a
translational deformity

43. LATERAL WEDGE OSTEOTOMY
 The lateral closing-wedge osteotomy is most commonly used for
cubitus varus because of its ease and simplicity.
 Lateral closing wedge osteotomy with a medial hinge will correct the
varus deformity, with some minor correction of hyperextension.
Types
1.Lateral closing wedge osteotomy (Voss et al)
2.French osteotomy
3.Modified french osteotomy

44.  The patient is positioned with the affected arm on an arm board and
a sterile tourniquet is used.
 A standard lateral approach is performed, distally utilizing the interval
between the anconeus and extensor carpi ulnaris muscles.
 Some surgeons advocate finding the radial nerve between the
brachialis and brachioradialis muscles at this point to ensure that it stays
protected throughout the surgery.

45.  This is helpful in older children and teenagers in whom a longer
lateral plate is required for fixation, which is more likely to endanger
the radial nerve, but it is not necessary when pin fixation is planned in
the skeletally immature patient.
 The principle behind this closing-wedge osteotomy is to plan a distal cut
parallel to the (altered) joint line and a proximal cut perpendicular to the
long axis of the humerus. The removal of the wedge then places
the joint line in proper alignment with the humeral axis.

46.  However, this technique is criticized for causing significant lateral
prominence. To minimize the lateral prominence, both cuts can be
made obliquely to recreate the same wedge angle without having the
distal cut completely parallel to the joint line.
 When pin fixation is planned, it is helpful to first place 2 Kirschner
wires in the lateral condyle distally, so that when the wedge is
removed, the pins can be driven across the osteotomy site into the
medial cortex.

47. Some surgeons prefer to completely cut the medial
cortex of the humerus, whereas others have
recommended leaving a medial cortical hinge.
Leaving an intact medial cortex allows for lesser fixation
methods, such as pins, because the osteotomy is
inherently more stable.
However, this technique then does not allow for
correction in the rotational or sagittal planes

48.  After the removal of the wedge, a standard supracondylar fracture
reduction maneuver of valgus, hyperflexion, and pronation is performed and
the preplanned Kirschner wires are driven across the osteotomy.
 If additional fixation is required, a third wire or a lateral plate can be used.
 Plate fixation may have an advantage over pin fixation in allowing earlier
mobilization, but it requires a more extensive dissection, is more technically
demanding, and may require future hardware removal.

49.  After closure, the patient is placed in a long-arm bivalved cast with a
plan for approximately 6 weeks of immobilization.

50. FRENCH OSTEOTOMY
 Posterior approach is used
• Detach the lateral half of the triceps from its insertion.
• Cortex is broken
• Medial periosteum left intact
• Approximate the cut surfaces, and correct the rotation deformity by
rotating the distal fragment externally until the distal screw is directly
distal to the proximal screw.

51. • Approximate the wedge till the 2 screws are parallel
 Two parallel screws that are attached by a single figure-of-eight wire that is tightened for
fixation.
• Danger of damaging the physis is minimized

52. Modified French Osteotomy
FRENCH
 Posterior longitudinal approach
 Lateral half of triceps detached
 Ulnar nerve explored
 Medial cortex broken
Modified FRENCH
 Posterolateral
 Whole triceps detached
 Ulnar nerve NOT explored
 Medial cortex intact (so more stable)

53. COMPLICATIONS:
1. Prominence of the lateral condyle: most common complication
This has been reported to occur in up to 60% of cases and arises more
commonly when the medial cortex is preserved for hinge stability.
2. Loss of correction when Kirschner wires alone are used for fixation.
3. Unacceptable scarring
4. Neuropraxia

54. Medial open wedge osteotomy
 A medial opening wedge osteotomy with external fixation and with or without bone graft.
 Advantage of this technique is that the alignment can be manipulated after the wound is
closed.
 Requires Bone Grafting
 Gains length→ inherent instability
 May stretch the ulnar nerve therefore transferred anteriorly to avoid this.

56. STEP CUT OSTEOTOMY
 A modification of lateral closing wedge osteotomy.
 Posterior approach to the distal humerus.
 Place the apex of the template (angle to be corrected) medially
• Using a template constructed preoperatively, make a lateral closing
wedge osteotomy in the metaphyseal region superior to the olecranon
fossa.
• Fixed with single cortical screw

58. TRANSLATIONAL STEP CUT
OSTEOTOMY
 Davids et al provides an excellent description of the translational step-cut osteotomy.
 The patient is positioned in either a prone or lateral position, with the humerus supported on
a padded post.
 A standard posterior approach to the elbow is used
 The triceps splitting approach offers the best visualization of the entire posterior aspect of the
distal humerus, which is required for this approach.
 The triceps muscle is split longitudinally after identification of its medial and lateral margins

59.  After identification of the distal humerus and superior margin of the olecranon fossa, the first
cut is a proximal transverse cut perpendicular to the axis of the humerus.
 The amount of correction needed is calculated as an angle, and a distal cut angled proximal-
medially to distal-laterally is made at this angle to the proximal transverse cut.
 This creates a lateral triangular wedge that is removed for the correction of the deformity.
 A rectangular wedge according to the size of the step cut is then made proximal and lateral to
the transverse cut.
 This rectangular segment is then removed to allow for translation and medialization of the
distal segment, which eliminates the lateral condylar prominence.

60. The cubitus varus is corrected by rotating the distal fragment laterally
and translating it medially.

61. SPIKE TRANSLATIONAL STEP CUT
OSTEOTOMY
 more complex requiring preoperative calculation of not only the varus
correction but also the necessary horizontal translation to correct the
lateral prominence.
 A paratricipital or olecranon osteotomy approach is used.
 A closing-wedge osteotomy is performed corresponding to the amount of
correction by comparing the carrying angle of both upper extremities.
 The inferior margin of the triangle is made parallel to the joint line 0.5 cm
above the olecranon fossa. The second line is drawn from medial distal to
proximal lateral to make the desired angle of correction.

62.  Next, from the lateral end of the second line a third perpendicular line is drawn distally
meeting the first line. This outlined triangle is now removed.
 The precalculated horizontal correction of the distal fragment is completed by translating the
distal fragment the appropriate distance on the proximal fragment.
 A corresponding triangular notch of bone is resected then from the proximal fragment to
match the distal fragment and the 2 are interdigitated.
 If planned preoperatively, internal rotational deformity is corrected through rotation of the
distal fragment. Plates and screws are used for fixation

64. DOME OSTEOTOMY
 The dome osteotomy is more technically demanding than either the
lateral wedge or the step-cut osteotomy.
 The dome osteotomy avoids the lateral prominence produced by
the lateral closing-wedge osteotomy while providing a large surface
area for fixation and healing, and the ability to “dial in” the desired
amount of correction.

65.  The patient is positioned in either a lateral or prone position, with the humerus supported on
a padded post. Either a triceps-splitting or para-tricipital approach can be used.
 After the exposure of the distal humerus, the olecranon fossa is identified.
 The center of the dome osteotomy (point A) is the point at which the midline axis of the
humerus intersects with the upper margin of the olecranon fossa.
 From point A, the base segment line AB is marked perpendicular to the midline axis of the
humerus.
 Line AB’ is then drawn parallel to the distal humeral articular surface. The length of AB’
determines the radius of the dome osteotomy.

66.  The arc of the dome osteotomy is marked with Kirschner wires and then drilled with a 3-0
cannulated drill bit.
 A quarter inch osteotome is used to finish the dome osteotomy.
 BAB’ marks the angle needed for correction.
 Point B’ on the distal fragment is then rotated to point B on the proximal fragment and
provisionally fixed with Kirschner wires.
 In young children, Kirschner wires alone are sufficient for fixation. In older children and
teenagers, however, standard distal humerus plates are used

68. Double dome osteotomy
 more fully address both the coronal and sagittal plane deformities in cubitus
varus.
 The first dome osteotomy was at the apex of the olecranon fossa, with the
center of the dome aligned with the humeral midline axis.
 The second dome osteotomy was also at the apex of the olecranon fossa, but
with the center of the dome aligned with the midline axis of the ulna.
 The 2 domes overlap, creating 2 semicircular wedges for removal

69.  After bone removal, the osteotomies are translated so that the humeral axis is aligned
with the ulnar axis, thus correcting the varus and extension deformity.
 Crosspin fixation is used for this double dome osteotomy.

71. COMPLICATIONS
1. Transient radial nerve palsy
2. Superficial infection
3. Excessive derotation

72. MULTIPLANAR OSTEOTOMY
 Multiplanar osteotomies can more accurately correct internal rotation than
uniplanar osteotomies, thus, allowing for anatomical positioning of the
distal humerus.
 Rotational deformity is difficult to understand through conventional
radiographs, and so accurate planning of multiplanar osteotomies requires
a preoperative computed tomography scan.

73.  This technique begins with a spiral computed tomography scan of both arms.
 Generate a surface 3-dimensional model for the radius, ulna, and humerus.
 Within the software, the entire affected arm and the healthy humerus are superimposed
to determine the correction of the deformity
 The greater tuberosity, humeral head, and shaft are used as proximal reference points,
and if possible the lateral and medial epicondyles are used as distal reference points

74.  The distal osteotomy plane is placed proximal to the olecranon fossa and parallel to the
distal surface of the humerus.
 Then, the proximal osteotomy plane is determined by the correction for the deformity in
relation to the distal osteotomy plane.
 On the basis of this model, the surgeon can then create patient-specific cutting guides as
well as custom surgical fixation devices if needed.

76. ISSUES:
 The first issue is access and cost effectiveness: A bilateral computed
tomography scan is required, which may not be readily available to all
patients.
 Another consideration is whether the correction of the internal rotation
deformity is even necessary:
Takagi et al have suggested that internal rotation correction does not affect
the outcome of cubitus varus corrections

77. CUBITUS VALGUS
 Cubitus valgus is a deformity in which the forearm is angled out away from
the body when the arm is fully extended.
 Carrying angle, or the degree to which your arm is angling away from your
body, exceeds 15 degrees.

78. CAUSES
1.Non union of lateral condyle fracture:
 proximal migration of the lateral condyle
 the cartilaginous articular surface of the distal fragment comes in contact with the
bony surface of the proximal fragment
 2. Malunited supracondylar fracture humerus
 3. Osteonecrosis of lateral trochlea
 4. Turner syndrome and Noonan syndrome

79. COMPLICATIONS
 1. Cosmetic
 2. Tardy Ulnar nerve palsy

80. Measurements
 1. The Humerus-elbow-wrist angle.
 2. flexion contracture: A flexion contracture of the elbow was measured with the medial and
lateral condyles held in the same horizontal plane with two fingers because, in patients with
cubitus valgus, as the elbow is extended the shoulder tends to rotate externally and mask
the true flexion contracture of the elbow

81.  The medial prominence index :
The index represents the difference between the medial and lateral widths of the distal part
of the humerus, as measured from the longitudinal midhumeral axis, and is expressed as a
percentage of the total width of the distal part of the humerus.

82. TREATMENT: OSTEOTOMY
 MILCH OSTEOTOMY:
 Patients lie in a lateral decubitus position under appropriate anaesthesia.
 Posterior V-Y triceps flap approach is used.
 The ulnar nerve was exposed, retracted medially and protected throughout
the procedure.
 A simple transverse osteotomy was performed at the intersecting point of
the forearm axis with the humeral axis using an oscillating saw.

83.  The distal end of the proximal fragment was notched in the middle to receive the apex of
the proximal end of the distal fragment.
 The distal fragment was adducted until the normal carrying angle was restored.
 The fragments were fixed by an appropriate plate and screws.

85. Step-Cut Translation Osteotomy with a
Y-Shaped Humeral Plate
 For severe deformity and extensive correction
• Uniplanar osteotomy that corrects deformities only in the coronal plane
• Posterior approach
• Dissect the soft tissue, and expose the ulnar nerve. In patients with ulnar
nerve palsy, perform an anterior subcutaneous transposition of the nerve.
 Perform the initial osteotomy 0.5 cm superior to the olecranon fossa,
perpendicular to the axis of the humeral shaft

86.  Move the medial edge of the distal fragment into the apex of
the proximal osteotomy site. The degree of correction
increases as the apex is moved laterally.
 The cubitus valgus is corrected by rotating the distal part of
the humerus medially and translating it laterally according to
the anatomical shape of the normal elbow.

87.  • Fixation with Y-shaped stainless steel plate. Apply three screws to the medial condyle and
two screws to the lateral condyle
 • In patients with cubitus valgus arising from nonunion of the lateral condyle, remove
impinging hypertrophic fibrous tissue followed by decortication of the bone and the
addition of a wedge-shaped graft.

88. Complications
 Stiffness
• Persistence of deformity – Over correction – Under correction
• Myositis ossificans
• Loss of fixation
• Neurovascular injury

89. THANK YOU