Cubitus varus

Cubitus Varus
INTRODUCTION
Cubitus varus (gunstock deformity) is a malalignment of the
distal humerus that results in a change of carrying angle from the
physiologic valgus alignment (5-15 degrees) of the arm and
forearm to varus malalignment.
= Gunstock deformity / bow elbow .
Normally arm 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.
Distal humeral deformity – varus , extension , internal rotation .
CAUSES
• Post-traumatic malunited supracondylar # (most common).
• Malunited intercondylar #.
• Malunited medial condyle #.
• Infective : medial growth plate damage .
• Vascular : osteonecrosis of trochlea.
• Neoplastic
INCIDENCE
• b/w 5-10yrs of age( basically in children due to immature skeleton ) .
• Reason : metaphyseal area of the distal humerus is the weakest region
around elbow , so s.c# are most common & frequent falls in children while
playing , cycling .
Functional limitation
• Limited flexion , due to hyperextension associated with varus malunion .
On Examination
 Inspection :
Hyperextension deformity
Limited flexion
Medial tilt and lateral angulation at elbow
Wasting of muscles
 Palpation :
lat.epicondyle appears prominent due to rotation of distal fragment .
Decrease in carrying angle .
3 point relationship do not make an equilateral triangle .
Graded by severity :
Grade I : loss of physiological valgus angle .
Grade II : 0-10⁰ of varus
Grade III : 11-20⁰ of varus
Grade IV : > 20⁰
INVESTIGATION
X-ray
AP-view :
Decrease in normal physiological valgus .
Increase in Baumann’s angle=Humero-capitellar angle , to assess the normal relationship
of distal humerus & measured on AP projection of elbow .
Lateral view :
Normally – no overlap b/w lat.epicondylar & olecranon epiphysis .
If – significant tilt of distal fragment +ve → overlap found = Crescent Sign .
TREATMENT
Surgical : corrective osteotomy
 Lateral wedge osteotomy
 Dome osteotomy ( less complication & maximum stability of
correction )
 Modified French osteotomy
 Medial open wedge osteotomy

French osteotomy Modified French osteotomy

Posterior longitudinal approach . Postero-lateral 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 .
FIXATION Modalities :
stabilisation methods vary from simple above elbow cast , k wires , Steinmann pin
, single or double cortical screw to screw with tension wire loops , plates & external
fixators .
In young child , wires should be used with smaller bone & should be used with
postoperative cast support .
Osteotomies with older children may be stabilised with one third tubular plate or
reconstruction plate . This will offer more rigid fixation with less chances of loss of
fixation & may allow early mobilisation depending upon stability of fixation .
Complications of osteotomy
• Persistant deformity , posterolateral elbow pain & instability .
• limitation of flexion range although functional arc maintained
• Stiffness ( myositis ossificans )
• Nerve injury (ulnar neuropathy / tardy ulnar nerve injury)
• Lateral prominence ( prominence of distal fragment – French osteotomy )
• Non-union
• Osteomyelitis (mostly in external fixation case )
• Scar
• Lateral condylar #
Thank you