Cubitus valgus varus

cubitus valgus and varus

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: 5-15 o  away from the body or 165-175 o  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. Hyperextension at elbow No widening of intercondylar region Internal rotation deformity with increased internal rotation ( Yamamoto test ) Decreased external rotation which is compensated by much more mobile shoulder joint (so often goes unnoticed by patients/relatives)

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

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

20. 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 ̊)

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

22. 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.

23. 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 ”

24. 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”

25. 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

26. 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

27. Osteotomies

28. 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

29. French Osteotomy Posterior approach 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. 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

30. 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

31. 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

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

33. 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

34. 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

35. 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

36. 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

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