CUBITUS VARUS AND VALGUS DEFORMITY .pptx

cubitus varus deformity, cubitus valgus deformity, clinical features, investigations, and treatment options. osteotomies around elbow. french osteotomy, lateral wedge, medial wedge, derotation osteotomies, dome osteotomy

1. CUBITUS VARUS AND VALGUS DEFORMITY Presented by - Dr Binod Chaudhary Department of Orthopaedics WRH, PoAHS

2. Contents Relevant anatomy Introduction Presentation Investigation Treatment

3. Relevant anatomy

4. Normal alignment of elbow joint is determined by measuring the carrying angle Normal carrying angle – 5 to 15 degrees More in females than male

5. Introduction Most common elbow deformity secondary to elbow fracture in children In addition to cosmetic appearance, may develop chronic pain, early osteoarthritis, ulnar neuropathy, posterolateral rotatory instability (PLRI) or triceps snapping over the long term Correction is commonly attempted through supracondylar humeral osteotomy; numerous surgical assistance methods have been designed

6. Definition Cubitus varus – it is a condition where the forearm is directed towards the midline Cubitus valgus – it is a condition where the forearm is directed away from the midline

7. Cubitus varus Aka gunstock deformity; a triplanar deformity with components of varus , hyperextension and internal rotation Forearm deviated inward with respect to arm at elbow with resulting lateral angulation in full extension Most common complication of displaced supracondylar fractures in children Incidence : 9% to 58%

8. Causes Infective: medial growth plate damage Vascular: osteonecrosis of trochlea Traumatic: supracondylar fracture, lateral condyle fracture Neoplastic; secondary to exostosis in distal, lateral humerus Congenital: epiphyseal dysplasia Malunited Supracondylar humerus fracture

9. 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 fracture

10. Smith has demonstrated that changes in the carrying angle are a result of angular displacement or tilting of the distal fragment, not translation or rotation Functional problems are almost always related to limitation of flexion, although tardy ulnar nerve palsy and elbow instability The limitation in flexion is a result of the hyperextension associated with varus malunion

11. Types Static (Non Progressive) Progressive

12. On examination Look Hyperextension deformity Limited flexion Medial tilt and lateral angulation at elbow Prominence of lateral condyle humerus Wasting of muscles

13. Feel Thickening and irregularity of supracondylar ridges Prominence (lateral condyle) Carrying angle Three point relationship

14. Classification Grades I – loss of the physiological valgus angle II – 0 to 10 degrees of varus III – 11 to 20 degrees IV – more than 20 degrees

15. Move 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 patient/relatives)

16. Measure Measurements on xrays : AP view Decrease in normal physiological valgus Increase in Baumann’s Angle(N=64-81 degrees) Metaphyseo-diaphyseal angle ( klebb -Sherman)  normal 90 degrees. Varus  >90 degrees valgus  <90 degrees Humero -ulnar angle (Oppenheim): decreased

17. 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

18. Treatment

19. Is it just A Crooked Elbow? Posterolatral rotatory instability (PLRI) Tardy ulnar nerve palsy Triceps dysfunction Dislocation of ulnar nerve Shoulder dysfunction Predisposition to fractures of lateral condyle

20. When to correct After full restoration of movement Rule out progressive deformity Usually after 3-6 months, for full motion to be regained Growth disturbances rare Do not have to wait for child to be 11 or 12 years old Wait one year( voss et al 1994)

21. What age to correct 6-11 yrs most appropriate Easier fixation Better cosmetic results Adequate bone stock by 6 Less remodeling by 11 Jain AK et al Arch.Orthop.Trauma.Surg (2000)

22. Treatment 3 modalities Observation with expected remodeling Hemiepiphysiodesis and growth alteration Corrective osteotomy

23. Observation Generally not appropriate Because, although hyperextension may remodel in a young child; in an older child, little remodeling occurs even in the plane of function of the joint

24. Hemiepiphysiodesis Rarely of value Only to prevent varus deformity with clear medial growth arrest or trochlear osteonecrosis If untreated, deformity will progress because of medial growth arrest and lateral overgrowth Lateral epiphysiodesis will not correct the deformity but will prevent it from increasing

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 x ray Wedge angle= Varus + Normal physiological valgus

26. 3 B asic T ypes Lateral closing wedge osteotomy Medial open wedge osteotomy with bone graft Oblique osteotomy with derotation

27. Center of Rotation of Angulation(CORA)

28. Lateral closing wedge osteotomy(Voss et al) Standard preparation, draping, tourniquet inflation Lateral incision at elbow With fluoroscopic guidance, insert 2 kwires into lateral condyle just distal to the planned distal cut. Advance proximally after making wedge osteotomy closing laterally.

29. French osteotomy Posterior approach Lateral closing wedge osteotomy with 2 guide pins and 2 screws inserted proximal and distal to the pins parallel to them. Medial cortex broken Only periosteum intact Approximate the wedge till the 2 screws are parallel Hold this position with TBW

30. The result of the French osteotomy are comparable with the more technically demanding dome, step-cut translation and multiplanar osteotomies, with a lower complication rate.

31. French vs Modified French osteotomy French osteotomy Modified French osteotomy Posterior longitudinal approach Posterolateral approach Detach whole of triceps Lateral half of triceps detached Ulnar nerve explored Ulnar nerve not explored Medial cortex broken Medial cortex intact so more stability

32. Step cut osteotomy Derosa and graziano A modification of lateral closing wedge osteotomy Make the osteotomy leaving a lateral spike of bone distally Correct the medial tilt, rotational mal alignment, hyperextension and fix with crossed k wires lag screw from lateral portion of distal fragment to proximal fragment. Close the wound and apply posterior splint for 4 weeks

33. Step cut translation osteotomy with a Y shaped humeral plate Posterior approach to distal humerus Incise the capsule to expose medial and lateral condyles Osteotomy with a triangular template 0.5 cm proximal to olecranon fossa with base of triangle perpendicular to humeral shaft and apex directed proximally Remove wedge of bone In cubitus varus , rotate distal fragment so as to fix its lateral border into v shaped apex of proximal fragment

34. Corrects deformity only in coronal plane Rotational deformity corrected in same operation by excising a piece of bone from posterior aspect of V-shaped proximal fragment. Correct rotation when angle of rotation differs by 10 from normal. Temporarily fix the correction by k wires. Smoothen the sharp edges of medial and lateral columns Fix with 3.5 mm plate with 5-6 screws distally and 2 screws proximally

35. Oblique osteotomy with Derotation Aims to correct rotational component but usually not necessary Types Amspacher and Messenbaugh correct a two plane deformity with one osteotomy Dome osteotomy with derotation (Uchida) Three dimensional osteotomy correction of medial tilt, internal rotation and posterior tilt

36. Amspacher and Messenbaugh Posterior approach Oblique osteotomy about 3.8 cm proximal to the distal end of the humerus , directing it from posteriorly above to anteriorly below Tilt and rotate the distal fragment until the internal rotation and cubitus varus have been corrected With the fragments in proper position, fix them with a screw inserted across the middle of the osteotomy

37. Dome osteotomy with derotation ( uchida et al) A type of osteotomy with derotation Preferred In mild cubitus varus 2 semicircular cuts made from lateral to medial 2 domes rotated and aligned to correct the deformity Corrects lateral prominence of condyle

38. Results Mean osteotomy healing time and mean time in external fixator was 10 wks Mean preoperative and postoperative carrying angles were 22 degrees of varus and 5.8 degrees of valgus.(p<0.001) High patient satisfaction. No neurovascular complications

39. Medial Opening wedge Osteotomy with bone grafting (king & Secor ) Requires bone grafting Disadvantages Gains length Creates a certain amount of inherent instability Stretches and damages the ulnar nerve (due to lengthening)

40. Study background To investigate the postoperative accuracy of a custom made surgical guide Study design Patients underwent 3d corrective osteotomy with use of a custom made surgical guide 3d model was created by superimposing mirror image of CT scans of contralateral elbow onto affected elbow

41. Cubitus Valgus

42. Increased physiological valgus with lateral tilt and medial angulation Carrying angle: superior to 15 Posterolaterally displaced fractures tend to develop valgus deviation

43. Causes Non-union fracture of 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

44. Presentation 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

45. Tardy Ulnar Nerve Palsy Due to gradual stretching of the ulnar nerve during the progression of valgus deformity of elbow Symptoms – tingling and paresthesia over ulnar nerve distribution Can also be seen in cubitus varus (friction neuropathy), medial condyle fracture, olecranon fracture and Monteggia fracture disloction

46. Investigations Plain radiograph AP and lateral view of elbow Assess the carrying angle Nerve conduction studies(tardy ulnar nerve palsy)

47. Treatment Deformity correction for cosmetic reasons Anterior transposition of ulnar nerve for Tardy ulnar nerve palsy

48. Options Observation with expected remodeling Corrective osteotomies

49. Osteotomy Milch devised two osteotomies Milch type I fracture(salter- harris type IV) Little lateral displacement when the nonunion is seen relatively early Cubitus valgus is usually not as marked Types: closing wedge medial osteotomy(speed) opening wedge lateral osteotomy ( milch ) Combine the osteotomy with an autogenous bone graft and smooth pin fixation to the epiphysis

50. Milch opening wedge displacement osteotomy In Milch II fractures, there is significant displactment of the fragment and some rotation Posterior muscle-splitting incision

51. Step-cut Translation Osteotomy with a Y shaped humeral plate ( kim et al) For severe deformity and extensive correction Uniplanar osteotomy that corrects deformity only in the coronal plane Posterior approach

52. Complications of Osteotomy Stiffness Nerve injury Persistent deformity (under-correction) Recurrent deformity Non-union Osteomyelitis Skin sloughing

53. Take home message Cubitus varus and valgus deformity is not uncommon Most complication of supracondylar fractures Essentially a cosmetic problem May lead to long term sequel Correction has to be planned carefully Avoid complications

54. References Azar FM, Canale ST, Beaty JH. Campbell's Operative Orthopaedics , E-Book. Elsevier Health Sciences; 2020 Dec 23. Miller MD, Thompson SR. Miller's review of orthopaedics . Elsevier Health Sciences; 2020. Solomon L, Warwick D, Nayagam S, editors. Apley's system of orthopaedics and fractures. CRC press; 2018. Related articles

55. Thank you