SUPRACONDYLAR OSTEOTOMY FOR CUBITUS VARUS

THE VALUE OF THE STRAIGHT ARM POSITION

0. F. McCOY, J. P10001

From Musgrave Park Hospital and The Royal Belfast Hospitalfor Sick Children

Supracondylar osteotomy for fraumatic cubitus varus is usually considered to be difficult, and to have a
significant incidence of complications. Most difficulty is in maintaining correction after operation.
We report 20 osteotomies performed by a modification of French’s technique and managed
postoperatively with the elbow extended. When a plaster splint was used only three ofseven cases had good or
satisfactory results, two requiring revision. Postoperative management by sfraight arm traction maintained
correction and achieved a good or satisfactory result in all 13 cases. This new technique is recommended.

Cubitus varus is by far the most common complication of of residual varus had immobilised the elbow postopera-
supracondylar fracture of the humerus in children. tively in a flexed position. This causes difficulty, because
Reports as to its incidence following severely displaced the carrying angle of the elbow cannot be accurately
fractures range from 4% (Piggot, Graham and McCoy assessed unless the elbow is fully extended and the
1986) to 58% (Hoyer 1952) with an average of around forearm supinated (Rang 1974). An extended arm also
30% (Smith 1960). Although functional impairment is allows better control ofthe carrying angle than is possible
rare, the deformity is significant ; parents often request a in flexion (Piggot et al. 1986). In addition, the dynamic
corrective operation. Cubitus varus is now accepted to effect of straight arm traction provides further stabilisa-
result from medial tilt of the distal fragment (Smith 1960; tion and permits the use of less extensive internal
Langenskiold and Kivilaakso 1967; Dowd and Hopcroft fixation. We report our experience of 20 corrective
1979). Earlier views that the cause was residual rotation osteotomies, 1 3 of which were managed in straight arm
(French 1959) or growth disturbance (Sins 1939; traction after operation.
Ho!mberg 1945) have now largely been discounted.
Despite the fact that most children’s fractures show a
MATERIALS AND METHODS
remarkable capacity for remodelling, an established
varus deformity does not improve with time. From November 1980 until January 1987, 20 corrective
Several corrective operations have been described. osteotomies for cubitus varus were performed on 13 girls
Sins (1939) advocated a cuneiform osteotomy, while and five boys; two were repeat operations, one for loss of
King and Secor (1951) recommended a medially-based fixation, and one for residual varus. All but one of the
opening wedge held with pins and a clamp. French, in patients had been treated in flexion for their original
1959, first described a lateral wedge osteotomy held with fractures.
screws and a figure-of-eight wire, and this remains the The average age at the time of fracture was 5.9 years
most popular method of correction. More recently, a (range 2.5 to 12.7 years) and at the time of operation it
number of workers have reported the use of variations of was 10 years (range 5.2 to 14.9 years). Pre-operative
French’s osteotomy (Carlson and Rosman 1982 ; Belle- varus deformity averaged 15.6#{176}
(range to 27#{176}).
5#{176} This
more et a!. 1984) but some authors had an unacceptable was graded by severity : Grade I was loss of the
incidence of residual varus (Alonso-L!ames, Diaz Pele- physiological valgus angle; Grade II was 0#{176} to 10#{176}of
tier and Moro Martin 1978 ; Oppenheim et a!. 1984). varus; Grade III, 1 1#{176}
to 20#{176}
and Grade IV more than 20#{176}.
Many ofthe authors who reported a significant incidence There were two Grade II deformities, 14 Grade III and
three Grade IV (one repeat procedure was performed for
loss of fixation and not for varus). The right elbow was
0. F. McCoy MD, FRCS, Senior Orthopaedic Registrar
Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic involved in 1 1 cases, the left in seven.
Centre, Headington, Oxford 0X3 7LD, England.
Technique of operation. All osteotomies were performed
J. Piggot, FRCS, Consultant Orthopaedic Surgeon
The Royal Belfast Hospital for Sick Children, 180 Falls Road, Belfast
by a modification of French’s method (1959). The
BT12 6BE, Northern Ireland. humerus is approached through a small lateral incision
directly over the supracondylar ridge, which is exposed
Requests for reprints should be sent to Mr 0. F. McCoy.
© 1988 British Editorial Society of Bone and Joint Surgery
subperiostea!ly. The size ofthe wedge is determined from
030l-620X/88/2060 $2.00 pre-operative radiographs, and two screws, preferably of
J Bone Joint Surg [Br] l988:70-B:283-6.
the Sherman type, are inserted through one cortex only,

VOL. 70-B, No. 2, MARCH 1988 283

284 G. F. McCOY. J. PIGGOT

above and below the proposed wedge (Fig. 1). In several with the restoration of a normal va!gus angle. One of the
cases, where rotational deformity was an additional cases treated in plaster had scarring from a superficial
feature, correction was attempted by placing the screws wound infection and was considered to have a poor result
in different positions in the sagittal plane. The wedge is on this basis. The postoperative range of flexion/exten-
cut with an oscillating saw, leaving the medial cortex sion was similar to the pre-operative, but mean recurva-
intact (Fig. 2) to be “cracked”, as a hinge, thereby turn was decreased by 4#{176}.
On the criteria given above,
approximating the screws (Fig. 3). The screws are then only one patient in this group had a good result, two were
wired together in a figure-of-eight fashion. The wound is satisfactory, having straight arms and three were poor
closed, with subcuticular suture for the skin. Consider- (two had revision and one had a keloid scar).
able correction is possible (Fig. 4). In all, 13 patients were treated in traction, 12
Postoperatively, the arm is maintained in the immediately after the first operation and one after
extended position for two weeks. For the first seven relapse in plaster and re-operation. The average pre-
cases, a long arm backslab was used but, in the more operative varus deformity was 14#{176}
(three Grade II, eight
recent 13 cases, straight arm traction has been more Grade III and two Grade IV). Mean correction was to 9#{176}
satisfactory. After release from traction, elbow flexion is valgus (range 4#{176}
to 1 5#{176}).
The range of flexion/extension
rapidly regained (Fig. 5). was increased on average by 5#{176},
with a 9#{176} reduction in

Fig. 1 Fig. 2 Fig. 3

The amount ofcorrection having been determined previously, screws are inserted above and below the level ofthe proposed wedge.
The laterally based wedge is then removed, and the osteotomy closed by approximating the screws.

At review from three months to four years after recurvatum. In one case treated in traction, the figure-of-
operation the degree of correction, the range of flexion eight wire broke, but, without further operation and with
and extension and the appearance of the scar were maintenance of traction, a correction to 5#{176}
valgus was
assessed, while any other problems with the elbow were achieved. Ten of the patients in the traction group
also recorded. achieved a good result, and three had a satisfactory
result. In two of these cases there was loss of more than
10#{176}of flexion/extension, but one of these patients was
RESULTS
assessed after only five months and further improvement
We considered a good result to be the restoration of could be expected. One patient had a florid scar but an
physiological valgus with no loss of range of flexion or otherwise good result. There were no poor results in the
extension and an acceptable scar. traction group. No nerve palsy was seen in either group
In the six patients treated entirely in plaster, the and there were no other significant complications.
average pre-operative deformity was 17#{176}
(five Grade III,
one Grade IV). Mean correction was to 1#{176}
varus and in only
DISCUSSION
one case was physiological valgus restored. In four cases,
the end result was a straight arm (cubitus rectus). In one The high rate of complications reported in some series
of these, the operation had to be repeated because of loss (Sweeney 1975. Oppenheim et al. 1984) deters many
of fixation. The sixth case in this group had relapse into surgeons from operating to correct traumatic cubitus
varus and required a revision operation, after which varus, and this reluctance is reinforced by the fact that it
management in traction gave a satisfactory outcome is performed for cosmetic reasons, and hardly ever to

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 SUPRACONDYLAR OSTEOTOMY FOR CUBITUS VARUS 285

position, the adequacy of the correction can be seen

during operation and, if necessary, adjusted.
We believe that postoperative management is
critical. As Rang (1974) maintains, the true carrying
angle cannot be determined until the arm is fully
extended and supinated. This makes postoperative
management in the flexed position inadvisable. Initially,
we believed that plaster would maintain an adequate
correction, but found that considerable loss of correction
was occurring, with four of our six cases relapsing to a
neutral position, and one into a varus position which
required re-operation. The weight of the plaster exerts a
varus force, and seems to be a major factor in the loss of
correction.
It is our policy to treat severely displaced fresh
supracondylar fractures in straight lateral traction as
originally described by Dunlop (1939), and our results
have been very satisfactory (Piggot et a!. 1986). Straight
arm traction gives excellent control of the carrying angle
and, when it is used after a corrective osteotomy, allows
Fig. 4 the use of less rigid internal fixation than would be
Radiographs of an elbow before and after treatment by osteotomy and required with the elbow in flexion. This, in turn, reduces
traction. the operative risks of nerve injury and infection.
improve function. Correction should therefore be easy to When fresh fractures are treated in straight lateral
perform, devoid of major complications and consistently traction, there is often a considerable delay before full
produce good results. e!bow flexion is regained, since this will depend heavily
Our modifications of French’s osteotomy appears to on remodelling. The capacity for remodelling is reduced
fulfil these criteria. The procedure is easy and, with in the older child undergoing osteotomy, and for this
experience, can be completed in under 30 minutes. There reason, the medial “hinge” is an important feature of the
is minimal dissection, and little possibility of nerve osteotomy. This hinge, with the screws and wire acting as
damage. By operating with the arm in the extended a bone suture, ensures that anatomical alignment is
maintained. Remodelling is not needed and elbow
flexion is rapidly regained especially since the fixation
allows mobilisation to start after two weeks rather than
the three weeks required for fresh fractures.
Our modification of French’s osteotomy, with a
period in traction, has given superior results to those of
most other series, traction affording good control of the
carrying angle. Even if fixation fails, as in one of our
cases, traction can still control the position. This simple
technique virtually eliminates many of the complications
which have previously been reported and we strongly
commend its use.

REFERENCES

Alonso-Llames M, Diaz Peletier R, Moro Martin A. The correction of

post-traumatic cubitus varus by hemi-wedge osteotomy. mt Orthop
1978 ;2 :215-8.
Bellemore MC, Barrett IR, Middleton RWD, Scougall JS, Whiteway
DW. Supracondylar osteotomy of the humerus for correction of
cubitus varus. J Bone Joint Surg [Br] l984:66-B:56&-72.
Carison ::s Jr, Rosman MA. Cubitus varus: a new and simple
Fig. 5 technique for correction. J Pediatr Orthop 1982:2:199-201.
Range of flexion and extension possible on the first day out of traction. Dowd GSE, Hopcroft PW. Varus deformity in supracondylar fractures
The scar is not prominent and will fade with time. of the humerus in children. Injury 1979:10:297-303.

VOL. 70-B, No. 2, MARCH 1988

286 BRIEF REPORTS

Dunlop J. Transcondylar fractures of the humerus in childhood. J Bone Oppenbeim WL, Clader TJ, Smith C, Bayer M. Supracondylar humeral
Joint Surg 1939:21 :59-73. osteotomy for traumatic childhood cubitus varus deformity. Clin
Orthop 1984:188:34-9.
French PR. Varus deformity of the elbow following supracondylar
fractures of the elbow in children. Lancet 1959:ii:439-41. Piggot J, Graham HK, McCoy GF. Supracondylar fractures of the
humerus in children : treatment by straight lateral traction. J Bone
Holmberg L. Fractures of distal end of the humerus in children. Acta
Joint Surg [Br] 1986;68-B:577-83.
C/sir Scand 1945:92 Suppl 103:1-69.
Rang M. Children’sfractures. 2nd ed. Philadelphia etc: JB Lippincott
Heyer A. Treatment of supracondylar fracture of the humerus by
skeletal traction in an abduction splint. J Bone Joint Surg [Am] Company, 1974.
1952:34-A :623-7. Sins IE. Supracondylar fracture of humerus : analysis of 330 cases. Surg
King D, Secor C. Bow elbow (cubitus varus). J Bone Joint Surg [Am] Gynecol Obsiet 1939:68:201-22.
1951 :33-A :572-6. Smith L. Deformity following supracondylar fractures of the humerus.
Langenskiold A, Kivilukso R. Varus and valgus deformity of the elbow J Bone Joint Surg [Am] 1960:42-A :235-52.
following supracondylar fracture of the humerus. Acta Orthop Sweeney JG. Osteotomy of the humerus for malunion of supracondylar
Scand 1967:38:313-20. fractures. J Bone Joint Surg [Br] 1975:57-B:1l7.

VITAMIN KLEVELS IN PROXIMAL FEMORAL FRACFURES:

BRIEF REPORT

L. KLENERMAN, B. D. FERRIS, J. P. HART

There is still controversy as to whether the two types of In a control group of 1 5 patients of comparable age and
proximal femoral fractures have different aetiology or sex, the circulating level measured by the same procedure
pathogenesis. Recently, in studying the detailed struc- was 335 (range, 284 to 386 pg/ml). This depressed level
ture of bone, it was shown that, with subcapital fractures, was comparable to that in patients who sustained
the orientation of the proteoglycans at the fracture site subcapital fractures. Thus, with respect to the deficient
was abnormal (Kent et al. 1983); however, with circulating levels of this bone-forming vitamin, as with
trochanteric fractures, the same abnormality was found the defective orientation of the proteoglycans, trochan-
at the site of the fracture (Ferris et al. 1987). teric fractures closely resemble subcapita! fractures.
In seeking other potential differences between these
fractures, attention was focused on the abnormally low Table I. Circulating vitamin K1 levels
circulating levels of vitamin K1 in patients with
Proximal Agein Sex
subcapital and spinal crush fractures (Hart et a!. 1985). femoral years ratio Mean kvel ± s.c.m.
Vitamin is involved in the y-carboxylation of fractures Number (range) (M:F) (j,g/nil)

g!utamic acid residues in osteocalcin and other bone Gla- Trochanteric 9 84 3:6 59 ± 13
proteins (Price 1983) which are required for the binding (65- 100)

of calcium for mineralisation. It therefore seemed Subcapital 14 77 1 :13 71 ± 9

relevant to test whether or not a similar circulating (63-83)

deficiency of vitamin occurred in patients with Control 15 63 5:9 335 ± 51

trochanteric fractures. (51-81)

Samples of blood (20 ml) were taken within 48 hours C From Hart et al. 1985.
from nine patients who had sustained trochanteric
fractures (as detailed in Table 1). The plasma was We acknowledge the help given us by Dr Lucille Bitensky and Dr J.
separated and assayed for vitamin content by Chayen of the Division of Cellular Biology, Kennedy Institute of
Rheumatology, London. One of us (BDF) is grateful to the Wellcome
electrochemical detection after separation by high Trust for a Fellowship for this work: JPH is grateful to the Arthritis
performance liquid chromatography (Hart et a!. 1985). and Rheumatism Council for Research for support.
The mean value was 59 pg/mI (range, 20 to 1 10 pg/rn!).
REFERENCES

Ferris BD, Dodds RA, Kienerman L, Bitensky L, Cliayen J. Major

L. Klenerman, ChM, FRCS, Professor of Orthopaedic and Accident components of bone in subcapital and trochant.eric fractures: a
Surgery comparative study. J Bone Joint Surg [Br] 1987 :69-B :234-7.
Royal Liverpool Hospital, Prescot Street, Liverpool L7 8XP, England. Hart JP, Shearer MJ, Klenerman L, et al. Electrochemical detection of
B. D. Ferris, MS. FRCS, Senior Registrar in Orthopaedic Surgery depressed circulating levels of vitamin K 1 in osteoporosis. J Clin
Whittington Hospital, London N19 SNF, England. Endocrinol Metab 1985:60:1268-9.
J. P. Hart, PhD, Lecturer Kent GN, Dodds RA, Bitensky L, Kknerman L, Watts RWE. Chayen J.
Chemistry Department, Bristol Polytechnic, Coldharbour Lane, Changes in crystal size and orientation of acidic glycosaminogly-
Frenchay, Bristol BSI6 lOX, England. cans at the fracture site in fractured necks of femur. J Bone Joint
Surg [Br] l983:65-B:189-94.
Correspondence to Professor L. Klenerman.
Price P. Osteocalcin. In : Peck WA, ed. Bone and mineral research,
© 1988 British Editorial Society of Bone and Joint Surgery
annual 1 . a yearly survey of developments in the field of bone and
0301-620X/88/2R52 $2.00
mineral metabolism. Amsterdam etc : Excerpta Medica,
J Bone Joint Surg [Br] 1988;70-B:286. l983:Chapter 4.

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