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Cubitus varus by Dhrumil Patel

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Cubitus varus by Dhrumil Patel

  1. 1. Dhrumil Patel 3rdYear Orthopaedic Resident CUBITUS VARUS
  2. 2. Cubitus Varus  Forearm deviated inwards with respect to arm at elbow with resulting lateral angulation in full extension.  Reduction of physiological valgus 8 ̊-15 ̊ ; Males : 10 ̊ Females : 15 ̊- 20 ̊
  3. 3.  Normally forearm is aligned in valgus with respect to arm in full extension with medial angulation.  Decrease in valgus with neutral alignment (loss of angulation) is called “Cubitus Rectus”. It is still a deformity as it deviates from the normal for population.
  4. 4. CUBITUS VARUS Varus deformity at elbow (CubitusVarus)
  5. 5. Causes 1. Post traumatic malunited s/c humerus fracture (most common) 2. Congenital (progressive) 3. Malunited fracture lateral condyle (progressive if due to hyperemia and overgrowth) 4. Trochlear Osteonecrosis (static) 5. Malunited intercondylar fracture (static) 6. Malunited medial condyle fracture (static)
  6. 6. Types  Static (Non progressive)  Progressive
  7. 7. ON EXAMINATION Inspection •Hyperextension deformity •Limited flexion •Medial tilt and lateral angulation at elbow •Prominence of lateral condyle humerus •Wasting of muscles •No scars/sinuses/redness
  8. 8.  PALPATION: • No local warmth/tenderness •Thickening and irregularity of supracondylar ridges • 3 point bony relationship maintained • Medial epicondyle tip higher
  9. 9. • 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)
  10. 10. DISPLACEMENTS THAT OCCUR AT ELBOW JOINT •Medial displacement •Medial tilt •Internal rotation •Posterior displacement •Posterior tilt •Proximal migration DISTAL FRAGMENT
  11. 11. “Gun-stock Deformity” – Looks like a loading stock of old long barrel guns
  12. 12. MEASUREMENTS ON XRAY :- AP VIEW •Decrease in normal physiological valgus •Increase in Baumann’sAngle (Normal – 64 ̊to 81 ̊)
  13. 13. •Metaphyseo-diaphyseal angle (Klebb-Sherman) Normally- 90 >Normal-Varus deformity <Normal-Valgus deformity •Humero-Ulno angle (Oppenheim) Decreased Most accurate
  14. 14. 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”
  16. 16. TREATMENT :- 3 MODALITIES 1. Observation with expected remodeling 2. Hemiepiphysiodesis and growth alteration 3. Corrective osteotomy Treatment is primarily “Cosmetic Correction”
  17. 17. 1. 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
  18. 18. 2. HEMIEPIPHYSIODESIS •Hemiepiphysiodesis of distal humerus is 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
  19. 19. 3. Corrective Osteotomy  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 (Metal wedge autoclaved)
  20. 20. 3 Basic Types  Lateral closing wedge osteotomy Easiest Safest Most stable inherently  Medial open wedge osteotomy with bone graft  Oblique osteotomy with derotation
  21. 21. Lateral closing wedge osteotomy (Voss et al.)  Standard preparation, draping, tourniquet inflation  Lateral incision at elbow  With fluoroscopic guidance, insert 2 K-wires into lateral condyle just distal to the planned distal cut. Advance proximally after making wedge osteotomy closing laterally.
  22. 22.  Keep medial cortex intact; weaken it by multiple drill holes and a Apply forceful valgus stress to complete the osteotomy .Close the osteotomy and advance the K-wires into the medial cortex of proximal fragment. Leave the wires buried under the skin. A third wire can be used if necessary for stability.  Close the wound in layers; splint the arm in 90 ̊ flexion and full pronation.
  23. 23. 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 •Approximately the wedge till the 2 screws are parallel •Hold this position withTBW
  24. 24. French Osteotomy Modified French Osteotomy (Bellemore)  Post. Longitudinal approach  Detach whole of triceps  Ulnar nerve explored  Medial cortex broken  Posterolateral approach  Lateral half of triceps detached  Ulnar nerve Not explored  Medial cortex intact so more stability
  25. 25. STEP-CUT OSTEOTOMY (DEROSA & GRAZIANO) •A modification of lateral closing wedge osteotomy •Using a template constructed preoperatively, make a lateral closing wedge osteotomy in the metaphyseal region superior to the olecranon fossa. •Make the osteotomy leaving a lateral spike of bone distally •Trim lateral portion of proximal fragment for close approximation. •Correct the medial tilt, rotational malalignment, hyperextension and fix with crossed K-wires •Then, use a lag screw from lateral portion of distal fragment to proximal fragment •Close the wound and apply posterior splint for 4 weeks.
  26. 26. STEP-CUT TRANSLATION OSTEOTOMY WITH A Y-SHAPED HUMERAL PLATE •Posterior approach to distal humerus. •Incise the capsule to expose medial and lateral condyles •Basic step-cut osteotomy involves 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 intoV- shaped apex of proximal fragment.
  27. 27. •In cubitus valgus, do fit the medial border of distal fragment into apex of proximal fragment leading to lateralization of the apex. •This basic step-cut translational osteotomy corrects deformity only in coronal plane. •Rotational deformity corrected in same operation by excising a piece of bone from posterior aspect ofV-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 3.5mm plate with 5 screws distally and 2 screws proximally.
  28. 28. OBLIQUE OSTEOTOMY WITH DEROTATION (AMSPACHER & MESSENBAUGH) •Patient prone and pneumatic tourniquet in place. •Posterior elbow exposure through a longitudinal incision; divide triceps in line with its muscle fibres, expose the s/c part of humerus subperiosteally protecting the radial and ulnar nerves. •Oscillating saw used to make an oblique osteotomy about 3.8cm proximal to distal end of humerus directing it posteriorly above to anteriorly below. Complete it anteriorly with osteotome.Tilt and rotate the distal fragment until cubitus varus and internal rotation have been corrected. •With fragments in position, fix them with a screw inserted across the middle of osteotomy. •Arm is immobilized in a long arm cast or splint until union at 4-6 weeks.
  29. 29. 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
  30. 30. MEDIAL OPEN WEDGE OSTEOTOMY WITH BONE GRAFTING (KING & SECOR) •Requires BG •Gains length→ inherent instability •May stretch the ulnar nerve- transferred anteriorly to avoid this
  31. 31. COMPLICATIONS OF OSTEOTOMY 1. Stiffness 2. Nerve injury 3. Persistent deformity (under correction) 4. Recurrent deformity 5. Non-union 6. Osteomyelitis 7. Skin sloughing
  32. 32. CUBITUS VALGUS Increased physiological valgus with lateral tilt and medial angulation Causes •Non-union fracture lateral condyle(>3months) •Malunited S/C fracture humerus •Osteonecrosis of lateral trochlea •Malunited intercondylar fracture •Radial head fracture dislocation •Medial epiphyseal injury and growth stimulation
  33. 33. Pseudo Cubitus Varus Lateral spur formation in lateral condyle humerus fracture due to elevation of periosteum and new bone formation leads to lateral bulge with normal carrying angle
  34. 34. ThankYou Next topic: Non-union by Dr. Sagar