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Cubitus Varus Osteotomy

intermediate Level

Primary Indication

Symptomatic cubitus varus deformity following malunited supracondylar humerus fracture, with cosmetic concerns, functional limitations, or risk of tardy ulnar nerve palsy or posterolateral rotatory instability

Danger Structures

  • Radial nerve (spiral groove proximally, mobile wad distally)
  • Posterior interosseous nerve
  • Lateral antebrachial cutaneous nerve
  • Brachial artery (medially)
  • Ulnar nerve (medially - avoid with medial K-wire)
  • Lateral collateral ligament complex

Visual Atlas

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Step-by-Step Technique

1

Position supine with arm on hand table, apply sterile tourniquet

Surgeon's Tip
EXAM KEY: Mark planned correction angle preoperatively - use carrying angle of opposite arm as guide (5-15° valgus)
Danger Zone
  • Inadequate preoperative planning
  • Wrong limb surgery
2

Make lateral incision from lateral epicondyle extending proximally 8-10cm

Surgeon's Tip
EXAM KEY: Stay posterior to lateral epicondyle to avoid radial nerve
Danger Zone
  • Radial nerve injury
  • Posterior interosseous nerve injury distally
3

Identify interval between brachioradialis (anterior) and triceps (posterior)

Surgeon's Tip
EXAM KEY: Can also use direct lateral approach splitting common extensor origin off lateral epicondyle
Danger Zone
  • Radial nerve in spiral groove proximally
  • PIN distally under supinator
4

Protect radial nerve by staying in correct interval or identifying and protecting it directly

Surgeon's Tip
EXAM KEY: Radial nerve runs anterior to lateral intermuscular septum then posterior at spiral groove
Danger Zone
  • Radial nerve contusion or laceration
  • Retraction injury
5

Elevate periosteum and expose distal humeral metaphysis at supracondylar level

Surgeon's Tip
EXAM KEY: Osteotomy at supracondylar level, above olecranon fossa, where bone is broadest
Danger Zone
  • Entering elbow joint
  • Inadequate exposure
6

Place K-wires as reference markers for rotational control before osteotomy

Surgeon's Tip
EXAM KEY: Reference wires allow you to assess rotation during correction
Danger Zone
  • Loss of rotational reference
  • Malrotation
7

Mark planned osteotomy - lateral closing wedge most common technique

Surgeon's Tip
EXAM KEY: Calculate wedge size preoperatively: wedge angle = carrying angle deficit + opposite arm valgus angle
Danger Zone
  • Incorrect wedge calculation
  • Asymmetric cuts
8

Perform lateral closing wedge osteotomy using oscillating saw

Surgeon's Tip
EXAM KEY: Cut from lateral - can do closing wedge (remove lateral bone) or opening medial wedge
Danger Zone
  • Medial cortex breach
  • Thermal necrosis
9

Alternatively, perform dome osteotomy for smoother correction without step-off

Surgeon's Tip
EXAM KEY: Dome osteotomy avoids prominence but technically more demanding
Danger Zone
  • Inadequate correction with dome
  • Instability of dome cut
10

Close wedge and correct varus deformity, verify carrying angle matches opposite side

Surgeon's Tip
EXAM KEY: Compare to opposite arm intraoperatively - carrying angle should be symmetric
Danger Zone
  • Under-correction
  • Over-correction to valgus
11

Correct any associated internal rotation deformity simultaneously

Surgeon's Tip
EXAM KEY: Many cubitus varus deformities have internal rotation component - assess preoperatively
Danger Zone
  • Missing rotational component
  • Creating external rotation deformity
12

Fix osteotomy with lateral locking plate, ensuring adequate distal fixation

Surgeon's Tip
EXAM KEY: Locking plate provides stable fixation. Consider crossing distal humeral columns for stability.
Danger Zone
  • Hardware prominence
  • Inadequate fixation in small distal fragment
13

Alternatively use crossed K-wires in children for fixation

Surgeon's Tip
EXAM KEY: K-wires acceptable in children - less hardware, allows growth. Must protect in cast.
Danger Zone
  • K-wire migration
  • Ulnar nerve injury with medial wire
14

Verify correction on fluoroscopy - check carrying angle and alignment

Surgeon's Tip
EXAM KEY: Full extension films compare carrying angle to opposite side
Danger Zone
  • Accepting residual deformity
  • Missing hardware complications
15

Close wound in layers, apply splint or cast depending on fixation stability

Surgeon's Tip
EXAM KEY: Above-elbow splint/cast for 4-6 weeks if K-wires, earlier ROM if stable plate fixation
Danger Zone
  • Wound complications
  • Stiffness from prolonged immobilization