1. Dhrumil Patel
3rdYear Orthopaedic
Resident
CUBITUS VARUS

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.  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. CUBITUS VARUS
Varus deformity at elbow
(CubitusVarus)

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)

7. Types
 Static (Non progressive)
 Progressive

8. 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

10.  PALPATION:
• No local warmth/tenderness
•Thickening and irregularity of supracondylar ridges
• 3 point bony relationship maintained
• Medial epicondyle tip higher

11. • 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)

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

13. “Gun-stock Deformity” – Looks
like a loading stock of old
long barrel guns

14. MEASUREMENTS ON XRAY :- AP VIEW
•Decrease in normal physiological valgus
•Increase in Baumann’sAngle
(Normal – 64 ̊to 81 ̊)

15. •Metaphyseo-diaphyseal
angle
(Klebb-Sherman)
Normally- 90
>Normal-Varus
deformity
<Normal-Valgus
deformity
•Humero-Ulno angle
(Oppenheim)
Decreased
Most accurate

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. CRESCENT SIGN

19. TREATMENT :- 3 MODALITIES
1. Observation with expected remodeling
2. Hemiepiphysiodesis and growth alteration
3. Corrective osteotomy
Treatment is primarily “Cosmetic Correction”

20. 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

21. 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

23. 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)

25. 3 Basic Types
 Lateral closing wedge osteotomy
Easiest
Safest
Most stable inherently
 Medial open wedge osteotomy with bone
graft
 Oblique osteotomy with derotation

26. 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.

28.  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.

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
•Approximately the wedge till the 2 screws are
parallel
•Hold this position withTBW

30. 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

31. 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.

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
•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.

35. •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.

37. 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.

39. 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

40. 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

41. COMPLICATIONS OF OSTEOTOMY
1. Stiffness
2. Nerve injury
3. Persistent deformity (under correction)
4. Recurrent deformity
5. Non-union
6. Osteomyelitis
7. Skin sloughing

42. 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

43. 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

44. ThankYou
Next topic: Non-union by Dr. Sagar