Cubitus varus and cubitus valgus are the most common complications of supracondylar humeral fractures in children. Cubitus varus causes the forearm to deviate inward with lateral angulation at the elbow joint. Cubitus valgus causes increased physiological valgus of the elbow. Both deformities can be treated with corrective osteotomy to realign the elbow if causing functional limitations or cosmetic concerns. Left untreated, cubitus valgus can sometimes lead to tardy ulnar nerve palsy due to nerve stretching over time.

1. Cubitus Varus
&
Cubitus Valgus

2. Malunion: Cubitus Varus and Cubitus Valgus
• most common complications of supracondylar humeral fractures.
• incidence : 0% to 50%.

3. Cubitus varus
• Forearm deviated inwards with
respect to arm at elbow with resulting
lateral angulation in full extension.
• Carrying angle : inferior to 5º
(Normal 5-15 deg)
• posteromedially displaced fractures
tend to develop varus angulation
• more common as posteromedial
fractures are more common.
• more cosmetically noticeable.
Cubitus Valgus
• Increased physiological valgus with
lateral tilt and medial angulation
• Carrying angle : superior to 15º
• posterolaterally displaced fractures
tend to develop valgus deviation

4. Carrying angle of the arm
(To assess Cubitus varus or valgus)
• the angle created by the medial border of
the fully supinated forearm and medial
border of the humerus, with the elbow
extended
• considerable individual variation.
• comparison should be made with the
contralateral side

5. • normal value: 5-15o away from the
body or 165-175o towards it.
• Cubitus varus: inferior to 5º
• Cubitus valgus: superior to 15º

6. • Carrying angle decreases with elbow extension, thus hyperextension
tends increases a cubitus varus deformity
• whereas a flexion contracture can create the appearance of cubitus
valgus

7. Problems arising from cubitus varus or valgus:
• Cosmetic deformity
• Functional limitation
• Recurrent elbow fracture
• tardy ulnar nerve symptoms

8. • cubitus valgus and varus are primarily cosmetic deformities
• mild degrees of malunion can be treated by simple reassurance.

9. • The resultant cubitus varus deformity is a combined
• deformity of varus
• extension
• internal rotation
• Most corrective osteotomies are to correct varus and extension deformity.
• The rotational deformity is well tolerated and best left untreated because
rotation of the distal fragment makes the osteotomy unstable.

10. CUBITUS VARUS
• Forearm deviated inwards with respect to
arm at elbow with resulting lateral
angulation in full extension.
• Carrying angle : inferior to 5º
• Synonyms – Bow elbow or Gunstock
deformity

11. Causes
• Post traumatic malunited supracondylar humerus fracture (most common)
• Malunited lateral condyle fracture
• Malunited intercondylar fracture
• Malunited medial condyle fracture
• NEOPLASTIC: secondary to exostosis in distal, lateral humerus
• Congenital : epiphyseal dysplasia
• VASCULAR : Trochlear Osteonecrosis
• INFECTIVE: medial growth plate damage

12. factors for malunion
• Impacted / comminuted type I supracondylar fractures
• Rotationally unstable type II fractures treated in a cast with
subsequent loss of reduction
• Poorly stabilized or reduced type III fractures or
• delayed neglected fractures

13. Patient presents with
• Previous history trauma to elbow
• history institutional treatment or local treatment
• Deformity of elbow joint – on extension of elbow
• Gunstock deformity
• Cosmetic problem No functional disability as such
• Ulnar nerve irritation

14. ON EXAMINATION
• Inspection
• Hyperextension deformity
• Limited flexion
• Medial tilt and lateral angulation at elbow
• Prominence of lateral condyle of humerus
• Gunstock deformity
• Wasting of muscles

15. “Gun-stock Deformity”
• Looks like a loading stock of old
long barrel guns

16. • PALPATION:
• Thickening and irregularity of supracondylar ridges
• Medial epicondyle tip higher

17. DISPLACEMENTS THAT OCCUR AT ELBOW JOINT
• Medial displacement
• Medial tilt
• Internal rotation
• Posterior displacement
• Posterior tilt
• Proximal migration
DISTAL FRAGMENT

18. Investigations:
• Plain radiograph of elbow AP and lateral view
• Assess the Carrying angle

19. MEASUREMENTS ON XRAY :- AP VIEW
Baumann’s angle or the shaft-physeal
angle
• between the longitudinal axis of the
humerus and a line through the physis
of the lateral condyle
• Decrease in normal physiological
valgus
• Increase in Baumann’s Angle
(Normal : 64 ̊to 81 ̊)

20. metaphyseal-diaphyseal angle
• between the long axis of the
humerus and a line connecting
the lateral and medial
epicondyles
• Normal: 72 to 95 degrees

21. humeroulnar angle
• formed between the long axis of
the humerus and the long axis of
the ulna
• Normal: 154 to 178 degrees
• most accurately depicts the true
carrying angle of the elbow.

22. LATERAL VIEW
• Normally no overlap between
the lateral condylar epiphysis
and olecranon epiphysis
• If significant tilt of distal
fragment occurs, there is overlap
between the two, which appears
like a crescent → ‘Crescent Sign”

23. TREATMENT :- MODALITIES
1. Observation with expected remodeling
2. Hemiepiphysiodesis and growth alteration
3. Corrective osteotomy
4. Distraction osteogenesis by Ilizarov technique
• Treatment is primarily “Cosmetic Correction”

24. Corrective Osteotomy
Pre-requisites
• At least 1 year following fracture (Bone remodeling and tissue
equilibrium)
• Patient demanding surgery
• Calculation of wedge to be removed
→ Normal side Xray → Wedge angle = Varus + Normal physiological Valgus

25. CORRECTIVE OSTEOTOMY
Options include:
• Medial open wedge osteotomy
• Lateral closing wedge osteotomy also known as French osteotomy .
• Oblique osteotomy with derotation.
• Dome osteotomy .
• Step cut osteotomy
• Arch
• Pentalateral

26. Osteotomies

27. Lateral closing wedge osteotomy
• approach the elbow through a lateral incision.
• Under C Arm, insert two K-wires into the lateral condyle before
osteotomy and advance them just distal to the planned distal cut.
• Make a closing wedge osteotomy laterally, leaving the medial
cortex intact.
• Weaken the medial cortex using drill holes.
• Apply a valgus stress to complete the osteotomy with the
forearm in pronation and the elbow flexed.
• Close the osteotomy and advance the K-wires from the lateral
condyle into the medial cortex of the proximal fragment.
• Leave the wires buried under the skin. A third wire can be used if
necessary for stability.
• Close the wound in layers and splint the arm in 90 degrees of
flexion and full pronation.
• A long arm cast can be applied in 5 to 7 days.
• The wires are removed at approximately 6 weeks after surgery

28. Step Cut Osteotomy (DeRosa and Graziano)
• 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

29. dome osteotomy
• Posterior approach
• avoid injury to the ulnar nerve
• The triceps muscle was split along the midline to expose the distal
humerus and olecranon.
• expose the metaphysis and diaphysis of the distal humerus.
• With full extension of the elbow, a semicircle with a radius of
approximately 3 cm from the center at approximately 1 cm distal to
olecranon tip was drawn on the surface of the distal humeral
metaphysis, the apex of the semicircle being proximal for
engagement of the lateral or medial condyle following osteotomy.
• A line was then added from the center of the semicircle to the end
point of the semicircle on the surface of the humerus, as a guide for
estimating the angle corrected.
• The osteotomy was completed with a small 1/4 inch osteotome and
the distal fragment was rotated coronally.
• After completion of the correction, the osteotomy was secured

30. COMPLICATIONS OF OSTEOTOMY
• Stiffness
• Nerve injury
• Persistent deformity (under correction)
• Recurrent deformity
• Non-union
• Osteomyelitis
• Skin sloughing

31. CUBITUS VALGUS
• Increased physiological valgus with
lateral tilt and medial angulation
• Physiological cubitus valgus varies from
3 to 29 deg
• Carrying angle : superior to 15º

32. Causes
• Non-union fracture lateral condyle of humerus
• Malunited supracondylar fracture humerus
• Osteonecrosis of lateral trochlea
• Malunited intercondylar fracture
• Radial head fracture dislocation
• Medial epiphyseal injury and growth stimulation

33. • History of fracture of lateral condyle of humerus
• Patient presents with external deformity of elbow joint
• Usually asymptomatic till patient develops TARDY ULNAR NERVE
PALSY

34. Tardy ulnar nerve palsy
• due to gradual stretching of the ulnar nerve during the progression of
valgus deformity of elbow
• Symptoms – tingling and paraesthesia over ulnar nerve distribution
• Can also be seen in cubitus varus (friction neuropathy), medial
condyle fracture, olecranon fracture and Monteggia fracture
dislocation

35. Investigations
• Plain radiograph AP and lateral view of elbow
• Assess the Carrying angle
• Nerve conduction studies

36. Treatment
• Deformity correction for cosmetic reasons – Osteotomies, Ilizarov
technique
• Anterior transposition of ulnar nerve for Tardy ulnar nerve palsy