This document discusses congenital and acquired deformities around the elbow. Congenital deformities include radial head dislocation and radio-ulnar synostosis. Acquired deformities result from trauma and fractures, leading to cubitus varus, valgus, and traumatic radioulnar synostosis. Surgical correction of deformities focuses on osteotomies to realign the elbow while minimizing complications. Most congenital conditions are asymptomatic, while acquired deformities often require surgery to address functional limitations, pain, or cosmetic concerns. A variety of surgical techniques can be used to correct elbow alignment, each with advantages and disadvantages.

1. Congenital and Acquired
Deformities around Elbow
Dr. Arun Upreti
Moderator: Dr. Nitish Bikram Deo

2. Contents
• Congenital
• Congenital Dislocation of Radial Head
• Congenital Radio-Ulnar Synostosis
• Acquired
• Cubitus Varus
• Cubitus Valgus
• Traumatic Radioulnar synostosis
• Monteggia fracture dislocation

3. Congenital Elbow deformities
Congenital Elbow dislocation
Elbow ankylosis – radio-humreal, ulno-humeral synosotsis
Pterygium
Congenital Radial head dislocation

4. Elbow Deformities
• Congenital – Radial head dislocation, Radio-ulnar synostosis
• Acquired – Cubitus varus, cubitus valgus, radio-ulnar synostosis
• Sporadic -
• Syndromic -
• Causes –
• Trauma – Cubitus varus, valgus,
• Infection - FFD
• Inflammatory conditions – Osteoarthritis sequala FFD
• Tumorous conditions – Congenital exostosis

5. Embryology
Proximo-distal: AER
Anterio-posterior: ZPA
Dorso-ventral: Wnt

6. Classification of Congenital Deformities
I. Failure of formation
II. Failure of part differentiation
III. Duplication
IV. Overgrowth
V. Undergrowth
VI. Constriction band syndrome
VII. Generalized skeletal abnormalities
Congenital Radial head dislocation and Congenital Radioulnar synostosis fall
under Failure to differentiate

7. Congenital Radial Head Dislocation
• Rare condition of unknown etiology
• May be isolated or associated with other conditions – Klienfelter,
Trisomy 13, Cornelia de Lange, Ehlers Danlos
• Direction of dislocation is usually posterior (2/3rd of cases)
• Presents after a perceived elbow injury
• Most patients have no functional limitation and or pain
• May complicate as cubitus valgus and ulnar neuropathy

8. Clinical features
Posterior dislocation

9. Radiographic Features

10. McFarland Diagnostic Criteria
• relative shortening of the ulna or
overlength of the radius,
• absence or hypoplasia of the capitellum
• grooving of the distal radius
• prominent ulnar epicondyle
• a partially defective trochlea and
• a dome-shaped radial head with a long
narrow neck

11. Difference between Traumatic and Congenital
Radial Head Dislocation
Differentiating Aspect Congenital Traumatic
Radial Head Dome shaped Normal concavity
Capitellum Hypoplastic Normal
Ulna Short and Bowed Normal
Bilaterality Common Uncommon
Other anomalies Common Uncommon

12. Treatment
• Most patients do not need any treatment
• Reduction – not recommended
• Radial head excision for progressive pain into the adulthood
• Operative management improves pain and cosmetic picture
• Complication – Cubitus valgus, PIN palsy, proximal overgrowth of
radius

13. Congenital Radio-ulnar synostosis (CRUS)
• Abnormal rigid connection between the proximal radius and ulna
because of erroneous embryologic development.
• Failure of longitudinal segmentation of limb bud results in CRUS
• Autosomal dominant inheritance pattern
• Associated with other conditions – Poland, Holt-Oram, Cornelia de
Lange, Cruzon, Apert

14. Clinical Features
• Most patients (57 -80%) are bilateral
• Usually a fixed pronation deformity ( Mean 60-70)
• Imaging shows radiographic fusion
• Radial head – dislocation, hypoplasia, mushroom shaped radial head
and dorsal subluxation of ulna at radius

15. Congenital Radio-ulnar synostosis
• Associated with – Alpert, Klienfelter,
Poland
• Isolated or Familial
• Bilateral in 80%
• Male more commonly affected
• Painless absence of FA rotation usually
in pronation

16. Classification
• Tachdjian
• Cleary and Omer (1985)
Type I Absence of radial head and osseous fusion proximally
Type II Radial head dislocation and osseous fusion proximally
Type III
No bony synostosis
Fibrous synostosis proximally
Type I Fibrous synostosis
Type II Osseous synostosis; radial head present; reduced
Type III Osseous synostosis; radial head present; posteriorly dislocated
Type IV Osseous synostosis; radial head present; anteriorly dislocated

17. Wilkie type I, Tachjidian Type II, Cleary and Omer Type III
Wilke Type II, Cleary and Omer Type II

18. Treatment
• Conservative treatment recommended for most cases
• Operative management – Indications not standardized
• Severe functional limitation
• >60 degree of pronation
• Bilateral involvement
• Surgical procedures – Mobilization procedures, Positioning
procedures

19. Surgical Procedures
• Mobilization procedures – Synosotosis resection with/without
vascular interposition (Kanaya procedure)

20. Surgical Procedures
• Positioning procedures: Osteoclasis, Detorational osteotomy, radial
head excision and the Ilizarov’s method
• Derotational osteotomy – Ulna and Radius osteotomy, Single radial
shaft ostetotomy,
• Position of the forearm – 0-20 of supination in non dominant hand
and 30 of pronation in dominant hand

21. Derotational Osteotomy

22. Cubitus Varus and Valgus
Deformity

23. Cubitus varus deformity
• Normally forearm is aligned in slight valgus in full supination and
extension of elbow
• Male : 8-15 Female: 15 to 20
• Decrease in the carrying angle constitutes varus deformity
• Usually a result of malunited supracondylar fracture
• A.k.a gunstock deformity

24. Carrying angle
• Carrying angle: used to assess varus
and valgus
• Considerable individual variation
• Bilateral comparisons is essential
• Elbow extension decreases carrying
angle
• Change in carrying angle is angular
deformity rather than translation or
rotation

25. Cubitus Varus

26. Etiology
• Upto 30% of Supracondylar fracture cases
• Other causes – Lateral condyle humeral fractures, physeal injuries,
osteonecrosis, infection and rarely tumorous condition
• Congenital cubitus varus – Epiphyseal dysplasia
• Triplanar malalignment of elbow characterized by varus angulation in
coronal plane, extension in saggital plane and internal rotation in
transverse plane
• Complications – Posterolateral rotatory instability, triceps snapping,
progressive ulnar and elbow varus, lateral humeral condyle fracture

27. Pathoanatomy – Varus malignment
LUCL attenuation during daily activities External rotation of ulna PLRI with subluxation of radial head

28. Imaging
• AP view: increase of Baumann’s Angle
• Lateral view: Hyperextension of distal fragment posterior to AHL

29. Imaging
• Imaging
• Metaphyseo-diaphyseal
angle
• Ulno-humeral angle
• Decreased
• Most accurate

30. Treatment
• Conservative – Expectant remodeling
• Corrective osteotomy
• Hemi-epiphysiodesis and growth alteration

31. Corrective Osteotomy
• Indications :
cosmetic concerns
 severe varus deformity,
 functional limitations
• Corrective osteotomy focuses on the correction of varus and
extension deformity.
• Rotational deformity is well tolerated and best left untreated because
rotation of the distal fragment makes the osteotomy unstable

32. CORRECTIVE OSTEOTOMY FOR CUBITUS
VARUS
• Lateral closing wedge osteotomy
• Medial opening wedge osteotomy
• Step-cut osteotomy
• Dome osteotomy
• External fixation with distraction osteogenesis

33. Lateral Closing Wedge Osteotomy
• Most commonly
used because of
ease and simplicity
• Distal cut: parallel to joint line, Proximal cut: perpendicular to long axis of humerus
• Leaving medial cortex Vs removing medial cortex
• Additional 3rd k wire Vs lateral plate fixation

34. Lateral Closing Wedge Osteotomy
• Lateral prominence
• Excision of wedge leaves two
bony fragment of unequal width;
tendency of distal fragment to
shift laterally
• Avoided by oblique osteotomy
(equal limb osteotomy)
• Unsightly surgical scar
• Loss of correction
• Due to tightness of medial soft
tissues after closing wedge
• Complications: 14-53%
• Lateral condyle prominence:60%

35. Medial Opening Wedge Osteotomy
• King and Secor described this
osteotomy
• Alignment can be manipulated
after the wound is closed
• Disadvantage:
• Requires bone graft
• Gains length→ inherent instability

36. Step-cut Osteotomy
Posterior approach: cosmetically better
Triangular osteotomy cut made 0.5-1 cm proximal to olecranon
fossa
Bone graft and Y-plate fixation

37. Dome Osteotomy

38. Complications of osteotomy
• Stiffness(myositis ossificans)
• Nerve injury(radial and ulnar nerve )
• Persistent deformity (under correction)
• Recurrent deformity
• Non-union
• Osteomyelitis
• Unsatisfactory scar
• Lateral prominence

39. Cubitus Valgus Deformity

40. Cubitus Valgus
• Carrying angle exceeds normal
physiological range
• Causes
• Non Union of Lateral Condyle of
humerus fracture
• Malunited Supracondylar fracture of
humerus
• Osteonecrosis of trochlea
• Complications – Tardy Ulnar Nerve
Palsy

41. Management
• Usually a history of recent or remote elbow fracture
• Carrying angle is measured
• Pain and instability are uncommon
• Ulnar neuropathy signs may be present
• Elbow motion is deficient while rotation is maintained
• X ray – to establish diagnosis and measure the deformity
• CT scan for complex cases

42. Cubitus valgus deformity

43. Management
• Nonsurgical treatment
• Asymptomatic patients with non progressive deformity
• Surgery – substantial deformity, progressive angulation and ulnar
nerve problem
• Goals of treatment – Bony union across lateral condyle, realignment
• Anatomic reduction of lateral condyle is avoided

44. Milch Osteotomy

45. Treatment
Step Cut Osteotomy Dome Osteotomy

46. Supracondylar vs Lateral Condyle Fractures
Supracondylar fracture Lateral Condyle fracture
Both varus and valgus deformities
• Posteromedial displacement: varus
• Posterolateral displacement: valgus
Both varus and valgus deformities
• Varus: Type II/III; associated lateral spur
• Valgus: established non-union
Varus is more common Valgus is more common
Varus is triplanar Varus is only in coronal plane (less severe than
supracondylar varus)
Deformity is mostly because of malunion:
medial column collapse
Deformity is mostly because of stimulation of
lateral condylar physis

47. Chronic Monteggia fracture
• Characterized by ulna fracture combined with radial head dislocation
• Over four weeks after injury = Neglected Monteggia fracture
• Causes – Ossification centers, non compliant in examination, fixation
ulnar fracture
• Pathophysiology – refractory dislocation of radial head and soft tissue
injury
• Capitellum – flat, degeneration of PRUJ

48. Diagnosis
• Symptoms – Antebrachial osseous protuneranc
• Radiological diagnosis of ulna, dislocation of redial head

49. Treatment
• Aim – correcting angular
deformity of ulna and
reduction of radial head
• Ulnar osteotomy, Reduction of
radial head, Reconstruction
annular ligament
• Some may require radial head
excision

50. Adult Post Traumatic Radioulnar synostosis
• Osseous or fibrous fusion of two forearm bones blocking pronation
and supination
• 2% of forearm fractures (Vince and Miller), upto 18% in patients with
head injury
• Risk Factors
• Trauma-Related: Monteggia fracture, fracture of both bones at same
level, open fracture, significant soft tissue lesion, high energy, osseous
fragments in IO membrane
• Treatment Related – Surgery, Single incision surgery, primary bone
graft, prolonged immobilization

51. Classification

52. Voila and Hasting Classification

53. Clinical Findings
• Prono-supination completely lacking
• Flexion/Extension lacking if humeroulnar or humeroradial synostosis
• Total-pain free, forearm blocked
• Incomplete – Limited painful prono-supination
• Radiographs are diagnostic
• CT scan determine extent of the synostosis and guide surgical
planning

55. Treatment

56. Summary
• Congenital deformity around elbow are rare conditions
• Most of congenital conditions do not cause functional limitations and
do not require treatment
• Acquired deformity around elbow are common following traumatic
fractures (supracondylar and lateral condyle fractures)
• Major indication for surgical treatment is cosmetic demand of
patients
• Different options for deformity corrections are available; each of
them have their pros and cons; no single technique is proven to be
superior

57. Thank You