Corrective osteotomy for gunstock deformity following malunited supracondylar fractures. The lateral closing wedge is the gold standard, with the medial cortical hinge providing inherent stability.
- Cubitus varus (gunstock deformity) is a triplanar deformity after a malunited supracondylar fracture: varus in the coronal plane, internal rotation (axial) and hyperextension (sagittal). It does NOT remodel significantly after age 2β3 years, which is what justifies surgical correction.
- The operation is primarily cosmetic: a neutral or negative carrying angle with patient or family concern, a good elbow range of motion (functional arc 30β130 degrees), and a minimum of 2 years since injury.
- Lateral closing wedge is the gold standard: remove a lateral wedge of bone and leave the medial cortex intact as a hinge for inherent stability and compression.
- The radial nerve is the highest-risk structure. It pierces the lateral intermuscular septum 10β12cm proximal to the lateral epicondyle, so at the osteotomy level it lies anterior between brachialis and brachioradialis β protect it with subperiosteal dissection and gentle retraction.
- Correction rule of thumb: 1mm of lateral wedge base width gives approximately 1 degree of correction. Aim for slight overcorrection (5 degrees of valgus is acceptable) because undercorrection is the most common error.
- Overcorrection to excessive valgus (greater than 15β20 degrees) is worse than undercorrection β it risks tardy ulnar nerve palsy years later. Normal carrying angle is 5β10 degrees valgus in males and 10β15 degrees in females; Baumann angle is normally 64β81 degrees.
When & Why
Indication. A symptomatic cubitus varus (gunstock) deformity β a neutral or negative carrying angle producing a visible gunstock appearance with the arm extended, with significant asymmetry compared with the contralateral side (typically greater than 15 degrees difference) β that has persisted for a minimum of 2 years after a supracondylar fracture. The deformity must be static, the patient or family must be bothered by the appearance, and the elbow must retain a near-full, functional range of motion (functional arc 30β130 degrees). Most surgeons operate between ages 6 and 12 years, before skeletal maturity; there is no upper age limit if symptoms warrant. Relative indications include posterolateral rotatory instability (a rare late complication), ulnar nerve symptoms from altered cubital tunnel mechanics, functional limitation from the deformity (unusual), and progressive deformity despite skeletal maturity. Contraindications. Absolute: active infection at the surgical site, severe elbow stiffness (an arc less than 60 degrees β the osteotomy will worsen it), vascular compromise or prior vascular injury, and skeletal dysplasia with abnormal bone quality. Relative: age less than 5 years (some remodeling potential remains), minimal deformity (less than 10 degrees of varus), unrealistic patient or family expectations, medical comorbidities increasing surgical risk, and expected poor compliance with rehabilitation.
Cubitus varus does NOT spontaneously remodel significantly after age 2β3 years, unlike many other paediatric fractures. The triplanar deformity (varus, internal rotation and hyperextension) persists and may even appear worse with growth. This is what justifies surgical correction of an otherwise cosmetic problem β functional range of motion is usually preserved despite the deformity.
Approach decision β lateral versus medial. The lateral approach (between brachioradialis and triceps) is the workhorse. The medial approach (anterior to the medial intermuscular septum) is reserved for selected cases.
Between brachioradialis (anterior) and triceps (posterior). Familiar anatomy, and the radial nerve can be identified and protected. The trade-off is a more visible scar and a higher radial nerve risk. Preferred by most surgeons for routine correction.
Anterior to the medial intermuscular septum. A better cosmetic scar (inner arm) and a lower radial nerve risk, but less familiar anatomy, and the ulnar nerve is at risk if the dissection strays posterior. Consider where cosmesis is paramount, or for revision cases with lateral scarring.
Consent specifically for: radial nerve injury (temporary in roughly 2β5 percent, permanent in less than 1 percent), residual deformity or the need for revision (undercorrection occurs in 10β20 percent), lateral condylar prominence, elbow stiffness, infection, K-wire or hardware issues, and a second procedure for hardware removal. Setup. Supine on the operating table with a radiolucent arm board extended at 90 degrees to the table, the affected arm on the board with the shoulder abducted 70β90 degrees, and C-arm access for AP and lateral fluoroscopy. Prepare the entire upper limb from the axilla to the fingertips. A sterile upper-arm tourniquet (200β250mmHg) is optional but helpful for haemostasis β if used, limit tourniquet time to less than 90 minutes and always release it before closure to verify neurovascular integrity and achieve haemostasis.
The Operation
The goal is to expose the distal humerus through the lateral approach, protect the radial nerve and the lateral antebrachial cutaneous nerve, cut a precisely templated lateral closing wedge that leaves the medial cortex as an intact hinge, close the wedge to restore 5β10 degrees of valgus, and fix it securely. The exposure is laid out in full as the first steps below.
Operative sequence
- Supine, radiolucent arm board at 90 degrees, shoulder abducted 70β90 degrees, C-arm available for AP and lateral fluoroscopy.
- Mark the lateral supracondylar ridge, the lateral epicondyle, and the planned incision centred 2β3cm proximal to the lateral epicondyle along the ridge.
- Exsanguinate and inflate a sterile upper-arm tourniquet to 200β250mmHg if used; plan to keep tourniquet time under 90 minutes.
- An 8β10cm longitudinal incision along the lateral supracondylar ridge, centred 2β3cm proximal to the lateral epicondyle, curving slightly posteriorly proximally and anteriorly distally.
- Identify and protect the lateral antebrachial cutaneous nerve (the terminal sensory branch of the musculocutaneous nerve) β it emerges between biceps and brachialis and crosses the field superficially. Gentle retraction, not division, prevents bothersome lateral forearm numbness.
- Ligate perforating vessels with bipolar cautery.
- Develop the plane between brachioradialis (anterior, identifiable by its muscle bulk on the anterior aspect of the lateral supracondylar ridge) and triceps (posterior, its lateral head on the posterior distal humerus) β a relatively avascular interval.
- Radial nerve anatomy is the key safety concept. The nerve pierces the lateral intermuscular septum 10β12cm proximal to the lateral epicondyle and then travels anteriorly between brachialis and brachioradialis. At the osteotomy level (2β3cm proximal to the epicondyle) it is therefore already anterior to the field β palpate it between the muscles proximally and protect it throughout with gentle retraction.
- Identify the lateral supracondylar ridge (the bony landmark) and elevate the brachioradialis origin subperiosteally from the lateral ridge.
- Elevate the triceps lateral head from the posterior distal humerus.
- Expose the circumference of the humerus at the osteotomy site, 2β3cm proximal to the olecranon fossa, staying subperiosteal to keep dissection deep to the radial nerve plane. Limit stripping to the osteotomy site to preserve blood supply.
- Confirm the osteotomy level with fluoroscopy: 2β3cm proximal to the olecranon fossa, entirely metaphyseal, clear of the physis and the joint.
- Transfer the preoperative template to bone. For a lateral closing wedge, the apex is medial (intact) and the base is lateral (removed). Mark the proximal and distal cut lines converging on the medial apex.
- Wedge size: base width in millimetres equals the correction in degrees (1mm gives approximately 1 degree). A 15-degree deformity corrected to 5 degrees of valgus needs a 20mm lateral base. Plan for slight overcorrection.
- Insert two 2.0mm reference K-wires β one parallel to the joint line distal to the osteotomy, one aligned with the humeral shaft proximally β to measure the correction angle before and after.
- Place Hohmann retractors subperiosteally around the circumference: anterior (protects brachialis and the neurovascular structures), posterior (protects triceps), and medial (protects soft tissues from the saw blade).
- With an oscillating saw and copious irrigation (to prevent thermal necrosis), make the proximal cut from the lateral cortex angled distally-medially toward the apex, and the distal cut from the lateral cortex angled proximally-medially toward the same apex.
- Preserve the medial cortex as a hinge: bring both cuts to within 2β3mm of the medial cortex, then gently complete it with a narrow osteotome or leave it as a greenstick to compress on closure. Save the removed wedge for autograft if needed.
- Apply medial-to-lateral compression to close the wedge, hinging on the preserved medial cortex, until the lateral cortices meet with bone-to-bone contact. Remove any interposed soft tissue.
- Clinical verification: compare the carrying angle to the contralateral elbow with the elbows extended and forearms supinated β aim for 5β10 degrees of valgus. Check rotational alignment of the distal fragment with the shaft (epicondylar axis).
- Fluoroscopic verification: AP Baumann angle 64β81 degrees and symmetric to the contralateral side; AP carrying angle 5β10 degrees of valgus; lateral anterior humeral line through the middle third of the capitellum. Clinical comparison is the most reliable final judge.
- Crossed K-wires (most common): 2β3 smooth 2.0mm K-wires from the lateral cortex, each obliquely across the osteotomy into the medial proximal cortex and crossing one another, with bicortical purchase. Leave them percutaneous, cut and bent outside the skin.
- Plate and screws (alternative): a 3.5mm reconstruction or 2.7mm paediatric plate applied to the lateral cortex as a tension band, typically 6β8 holes. More stable and allows earlier mobilisation, at the cost of more dissection and later hardware removal.
- Maintain compression during fixation, confirm position and joint clearance on fluoroscopy, and stress gently in varus and valgus to confirm stability.
- Release the tourniquet (if used) before closure, wait at least 10 minutes for vasospasm to resolve, and confirm a strong radial pulse, capillary refill under 2 seconds, and good limb perfusion.
- Document radial nerve function (wrist, thumb and finger MCP extension), posterior interosseous nerve function, and median and ulnar nerve function. Any new deficit mandates immediate nerve exploration β do not close and hope.
- Achieve haemostasis; consider a small drain only if there is significant ooze, since a haematoma can compress the radial nerve and cause a delayed palsy.
- Copious saline irrigation; layered closure β periosteum and deep fascia (2-0 Vicryl), subcutaneous tissue (3-0 Vicryl buried), and skin (subcuticular 4-0 Monocryl or interrupted 4-0 nylon) with skin adhesive or Steri-Strips.
- Apply a posterior elbow splint (not a circumferential cast) with the elbow at 90 degrees and the forearm in neutral rotation, from mid-humeral level to the metacarpal heads, leaving the MCP joints free. Pad the olecranon and epicondyles and keep the fingertips visible for neurovascular monitoring.
- Give a single preoperative dose of cefazolin (25β50mg/kg).
The radial nerve pierces the lateral intermuscular septum 10β12cm proximal to the lateral epicondyle and is therefore anterior to the osteotomy site. Subperiosteal elevation at the metaphyseal level keeps the dissection deep to the nerve; the nerve is most at risk from retractor pressure or excessive traction during bone manipulation, not from the saw cuts themselves. Identify its course early, use Hohmann retractors subperiosteally, and avoid excessive cautery along the nerve. Most radial nerve palsies are neuropraxias recovering in 3β6 months, but a complete immediate deficit warrants exploration.
Preserve the medial cortex by stopping the saw cuts 2β3mm short of it and gently completing or greensticking it on closure. The intact hinge provides inherent stability and compression at the osteotomy, which is why crossed K-wires are usually adequate. If the medial cortex is accidentally completely transected, the osteotomy becomes unstable and needs plate fixation, with a higher non-union risk.
Aim for slight overcorrection (5 degrees of valgus is acceptable) because undercorrection (10β20 percent) is the most common error. But stop there β overcorrection to excessive valgus (greater than 15β20 degrees) is worse than undercorrection, as it risks tardy ulnar nerve palsy years later and is difficult to reverse.
Aftercare & Complications
Rehabilitation | Phase | Timing | Immobilisation | Therapy and activity | |-------|--------|----------------|----------------------| | 1 | 0β2 weeks | Posterior splint (elbow at 90 degrees) | Finger active ROM only; neurovascular checks | | 2 | 2β6 weeks | Removable splint or sling | Active-assisted elbow ROM (no passive stretching); wound review and radiographs at 7β10 days | | 3 | 6β12 weeks | Splint for heavy tasks only | Progressive ROM; K-wire removal at 6β8 weeks once callus is adequate | | 4 | 12 weeks and beyond | None | Strengthening; return to contact sport once solid union | Early active range of motion (starting at 1β2 weeks once the wound has healed) is essential β historical prolonged immobilisation caused stiffness. Active motion is safe and beneficial; passive stretching risks fixation failure and is avoided until solid union at 8β12 weeks. Good-to-excellent results are reported in around 88 percent of patients in pooled systematic-review data (Solfelt 2014), with a mean angular correction of about 27.6 degrees; the overall complication rate is around 14.5 percent, with nerve palsy in about 2.5 percent (roughly 78 percent transient). Long-term follow-up (Ippolito 1990) shows function is durable though cosmetic correction can partially recur, especially when the original injury involved physeal damage. Complications
- Recognition
- Wrist drop, weak finger MCP and thumb extension, sensation loss in the first dorsal web space; usually immediate, or delayed 24β48 hours from haematoma
- Prevention
- Know the anatomy β the nerve is anterior at the osteotomy level; subperiosteal dissection, early identification, gentle Hohmann retraction, avoid excessive cautery; meticulous haemostasis
- Management
- Most are neuropraxias recovering in 3β6 months: cock-up wrist splint, hand therapy, EMG at 6 weeks; explore if complete immediate deficit or expanding haematoma
- Recognition
- Intrinsic weakness, clawing of ring and little fingers, ulnar sensation loss; tardy ulnar palsy if overcorrected to excessive valgus
- Prevention
- On the medial approach stay anterior to the medial intermuscular septum; identify and protect the nerve; avoid overcorrection beyond 20 degrees of valgus
- Management
- Primary microsurgical repair if divided; observe neuropraxia with hand therapy; cubital tunnel release with or without transposition for tardy palsy
- Recognition
- Persistent neutral or varus carrying angle versus the contralateral side; patient or family dissatisfaction
- Prevention
- Accurate templating on bilateral radiographs; 1mm base equals 1 degree; intraoperative goniometer and fluoroscopy; err on slight overcorrection
- Management
- Mild (less than 10 degrees) may be accepted and partly remodels in young children; significant (10β15 degrees or more) with dissatisfaction β revision osteotomy at least 6, ideally 12 months out
- Recognition
- Excessive valgus versus the contralateral side (typically greater than 15 degrees); functional issues; late tardy ulnar nerve palsy
- Prevention
- Careful templating; compare intraoperatively to the contralateral side; 5 degrees of valgus is acceptable, stop there
- Management
- Mild (10β15 degrees) β observe for ulnar nerve symptoms; severe (greater than 20 degrees) β reverse (medial closing wedge) osteotomy; address tardy ulnar palsy with transposition plus corrective osteotomy
- Recognition
- Palpable lateral bump at the osteotomy site, apparent once swelling subsides; cosmetic, occasionally tender
- Prevention
- Remove adequate lateral bone when taking the wedge; smooth sharp edges with a rongeur or burr; close the wedge fully with good apposition
- Management
- Reassure β remodels partially over 6β12 months; resect the prominence at hardware removal if cosmetically concerning
- Recognition
- Reduced flexion-extension arc versus baseline; worse after prolonged immobilisation (more than 3 weeks)
- Prevention
- Early active ROM at 1β2 weeks; adequate pain control and hand therapy; stable fixation; avoid passive stretching until union
- Management
- Active and active-assisted ROM; once united add passive stretching; dynamic splinting; capsular release (open or arthroscopic) for severe stiffness (arc less than 60 degrees) persisting 6β12 months
- Recognition
- Change in alignment on follow-up radiographs (weeks 2β6); return toward varus; K-wire backing out
- Prevention
- Minimum 2 crossed K-wires with bicortical purchase (3 wires or a plate if unstable); preserve the medial hinge; restrict activity until union
- Management
- Early loss (before 2 weeks) β revise fixation; later loss with partial healing β accept if alignment acceptable, else revise; near union β observe and reassess
- Recognition
- Superficial: wound erythema, drainage; deep: systemic symptoms, raised inflammatory markers; pin-site infection around K-wires
- Prevention
- Preoperative cefazolin (25β50mg/kg), sterile technique, haemostasis, pin-site care
- Management
- Superficial β oral antibiotics and wound care; pin-site β oral antibiotics, early K-wire removal if callus adequate; deep β IV antibiotics and surgical debridement, retain hardware if within 3 weeks and stable
- Recognition
- Wire backing out through the skin (most common) or migrating on serial radiographs; pin-site irritation
- Prevention
- Bicortical purchase, slight bend outside the skin, smooth wires, 2β3 wires for stability
- Management
- Minor backing out β monitor or remove early if callus adequate; through the skin β cover and remove once healing allows (minimum 4β6 weeks); migration toward joint or neurovascular structures β urgent removal
- Recognition
- Failure of union by 6 months; persistent pain and tenderness; radiographic lucency and hardware loosening
- Prevention
- Stable fixation, preserve periosteal blood supply, good bone apposition, avoid smoking
- Management
- Revision with autograft (iliac crest) and compression plate fixation; address contributing factors
Viva & Exam Focus
CUBITUSCUBITUS β components and pitfalls of cubitus varus
RADIALRADIAL β protecting the radial nerve
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
βAn 8-year-old presents with cubitus varus 3 years after a supracondylar fracture. Describe your assessment and when you would offer surgical correction.β
βImmediately after a lateral closing wedge osteotomy the child has a wrist drop. What are your differentials and your management?β
βAt the 3-month follow-up the radiographs show 5 degrees of residual varus and the family is unhappy with the cosmetic result. How do you manage this?β
Indication
- Primarily cosmetic: neutral or negative carrying angle with concern, good elbow ROM (arc 30β130 degrees), minimum 2 years post-injury
- Cubitus varus is triplanar and does NOT remodel after age 2β3 years
Anatomy at risk
- Radial nerve β pierces the lateral intermuscular septum 10β12cm proximal to the lateral epicondyle, anterior at the osteotomy level
- PIN β avoid distal dissection beyond the lateral epicondyle
- Ulnar nerve β at risk on the medial approach or if overcorrected to valgus
Planning
- Bilateral AP radiographs, elbows fully extended; Baumann angle (normal 64β81 degrees) is most reliable
- 1mm lateral wedge base equals 1 degree of correction; plan slight overcorrection (5 degrees of valgus)
- Osteotomy level 2β3cm proximal to the olecranon fossa, metaphyseal, clear of physis and joint
Technique
- Lateral approach between brachioradialis and triceps; subperiosteal exposure
- Lateral closing wedge β two saw cuts to a medial apex, preserve the medial cortex as a hinge
- Verify correction clinically (compare to contralateral) and fluoroscopically (Baumann angle)
- Fixation β crossed K-wires (usual) or a lateral plate
Safety
- Radial nerve: subperiosteal dissection, early identification, gentle retraction
- Verify neurovascular status and release the tourniquet before closing β document radial nerve function
- Overcorrection to greater than 15β20 degrees of valgus is worse than undercorrection (tardy ulnar nerve palsy)
Complications
- Undercorrection (10β20 percent, most common), overcorrection (5β10 percent), stiffness (10β15 percent)
- Radial nerve injury (2β5 percent, mostly transient), lateral prominence (5β10 percent), infection (1β2 percent)
- Pooled data: 88 percent good or excellent, 14.5 percent complications, 2.5 percent nerve palsy
Aftercare
- Posterior splint (not circumferential) for 1β2 weeks, then a removable splint
- Active ROM from 1β2 weeks β no passive stretching until union at 8β12 weeks
- K-wires out at 6β8 weeks; return to contact sport once solid union
Background & Evidence
Pathoanatomy β why cubitus varus is triplanar. The deformity follows malunion of a paediatric supracondylar fracture in 10β15 percent of cases (Karatosun 2000), with the varus arising from malunion rather than growth disturbance in most patients (Bellemore 1984). Because the distal fragment settles in medial rotation and extension as well as varus, the result is a triplanar gunstock deformity: varus in the coronal plane, internal rotation axially, and hyperextension sagittally. A simple lateral closing wedge corrects the coronal varus; for a complete three-dimensional correction, a dome, step-cut or 3D-guided osteotomy is needed (Takeyasu 2013). Epidemiology. Cubitus varus is the most common late complication of a supracondylar humeral fracture in children. Malunion is the dominant mechanism; genuine growth disturbance from physeal injury is less common but, when present, predicts loss of correction over time (Ippolito 1990). The deformity is essentially a cosmetic and rotational problem β functional range of motion is usually preserved. Key measurements.
- Normal
- 5β10 degrees valgus (males), 10β15 degrees (females)
- In cubitus varus
- Neutral to negative (0 to -30 degrees)
- Use
- Primary clinical measure β compare to the contralateral side; radiographic measurement is unreliable
- Normal
- 64β81 degrees
- In cubitus varus
- Decreased (less than 64 degrees)
- Use
- Most reliable radiographic measure β angle between the humeral shaft and the lateral condyle physis
- Normal
- Symmetric to the contralateral side
- In cubitus varus
- Reduced on the affected side
- Use
- Overall alignment from shoulder to wrist
- Normal
- Through the middle third of the capitellum
- In cubitus varus
- Passes posterior to the capitellum in extension deformity
- Use
- Assesses the sagittal (hyperextension) component
Alternative osteotomy techniques. The lateral closing wedge is the workhorse; other techniques address specific needs. No single technique has been shown to be statistically safer or more effective (Solfelt 2014).
- Advantages
- Simple, stable medial hinge, familiar, reliable
- Disadvantages
- Lateral scar and prominence, slight shortening
- Best for
- Routine cubitus varus correction
- Advantages
- Corrects valgus, less radial nerve risk, less lateral prominence
- Disadvantages
- Ulnar nerve at risk, less stable hinge, less familiar
- Best for
- Cubitus valgus, revision with lateral scarring
- Advantages
- No shortening, precise correction, medial hinge intact
- Disadvantages
- Needs bone graft, delayed union risk, more complex
- Best for
- When length must be maintained
- Advantages
- Multiplanar correction, stable
- Disadvantages
- Technically demanding, longer surgery
- Best for
- Complex three-dimensional deformity, revision
- Advantages
- Inherently stable, large contact area, addresses rotation
- Disadvantages
- Technically demanding, needs careful planning
- Best for
- Revision, poor bone quality
- Advantages
- Addresses all three planes simultaneously
- Disadvantages
- Needs CT and a custom guide
- Best for
- Complex or revision triplanar deformity
References
Supracondylar osteotomy for the treatment of cubitus varus in children: a systematic review
- 894 children across 40 studies; mean age 5.7 years at injury and 9.8 years at corrective osteotomy
- Four technique classes compared (lateral closing wedge, dome, complex or multiplanar, distraction osteogenesis); mean angular correction 27.6 degrees (range 18.5 to 37.0)
- Pooled good-to-excellent results 87.8 percent (95 percent CI 84.4 to 91.2); no single technique was statistically safer or more effective than another
- Overall complication rate 14.5 percent (95 percent CI 10.6 to 18.5); nerve palsies in 2.53 percent, of which 78.4 percent were transient
Preoperative, computer simulation-based, three-dimensional corrective osteotomy for cubitus varus with a custom-designed surgical device
- 30 consecutive patients corrected using a CT-based 3D simulation and a custom cutting and reduction template
- Mean humerus-elbow-wrist angle improved from 18.2 degrees varus to 5.8 degrees valgus; hyperextension and shoulder internal rotation normalised in all
- Bone union at a mean of 4 months; 27 excellent, 3 good, none poor
- Complications limited to one early plate breakage and one mild varus recurrence
Post-traumatic cubitus varus: long-term follow-up of corrective supracondylar humeral osteotomy in children
- 24 patients followed to skeletal maturity (mean age 7.9 years at surgery, 31 years at review)
- 7 good, 6 fair, 11 poor; 17 of 19 measured patients lost some operative correction over time
- Correction was best maintained where the deformity was pure metaphyseal malunion; it was lost when the original injury involved physeal damage
- 14 of 24 were dissatisfied with cosmesis, yet all but three retained good elbow function
Supracondylar osteotomy of the humerus for correction of cubitus varus
- 32 patients over a 10-year period; results reviewed in 27
- Cubitus varus is the most common complication of paediatric supracondylar fracture, usually from malunion rather than growth disturbance
- The carrying angle was reliably restored by supracondylar (lateral closing-wedge) osteotomy
- 16 patients treated with the French (1959) lateral closing-wedge technique, which proved safe and satisfactory
Further reading 1. Takeyasu Y, Oka K, Miyake J, Kataoka T, Moritomo H, Murase T. Preoperative, computer simulation-based, three-dimensional corrective osteotomy for cubitus varus deformity with use of a custom-designed surgical device. J Bone Joint Surg Am. 2013;95(22):e173. PMID 24257673. Level IV (case series, 30 patients). CT-based 3D simulation corrected the triplanar deformity; mean humerus-elbow-wrist angle improved from 18.2 degrees varus to 5.8 degrees valgus. 2. Ippolito E, Moneta MR, D'Arrigo C. Post-traumatic cubitus varus. Long-term follow-up of corrective supracondylar humeral osteotomy in children. J Bone Joint Surg Am. 1990;72(5):757-765. PMID 2355039. Level IV (mean 23-year follow-up). Cautionary: most patients lost correction over time; only 7 of 24 good and 11 of 24 poor; 14 of 24 dissatisfied cosmetically. Function remained good despite recurrent deformity. 3. Karatosun V, Alici E, GΓΌnal I, Γakmak M, IΕik M. The effect of closed reduction on the development of cubitus varus after supracondylar fractures of the humerus in children. J Bone Joint Surg Br. 2000;82(7):1030-1033. Level III. Malunion with varus is the primary cause; it occurs in 10β15 percent of supracondylar fractures and does not remodel significantly after age 3. 4. Ring D, Waters PM. Operative fixation of malunited fractures of the distal humerus in children. J Bone Joint Surg Br. 1996;78(5):784-789. Level IV. Corrective osteotomy achieves good correction but 15β20 percent have residual deformity from inadequate initial correction. 5. Davids JR, Maguire MF, Mubarak SJ, Wenger DR. Lateral condylar prominence: a sign of cubitus varus. J Pediatr Orthop. 1993;13(3):348-351. Level IV. Lateral condylar prominence is a common finding (5β10 percent) after a lateral closing wedge; it usually remodels but may need resection. 6. Bellemore MC, Barrett IR, Middleton RW, Scougall JS, Whiteway DW. Supracondylar osteotomy of the humerus for correction of cubitus varus. J Bone Joint Surg Br. 1984;66(4):566-572. PMID 6746695. Level IV (32 patients). Confirms cubitus varus is usually a malunion rather than a growth disturbance and that the carrying angle can be reliably restored. 7. Kim HT, Lee JS, Yoo CI. Management of cubitus varus and valgus. J Bone Joint Surg Am. 2005;87(4):771-780. Level V (review). Comprehensive review of the triplanar pathoanatomy and the treatment options. 8. Uchida Y, Ogata K, Sugioka Y. A new three-dimensional osteotomy for cubitus varus deformity after supracondylar fracture of the humerus in children. J Pediatr Orthop. 1991;11(3):327-331. Level IV. Dome osteotomy for simultaneous correction of the triplanar deformity. 9. Labelle H, Bunnell WP, Duhaime M, Poitras B. Cubitus varus deformity following supracondylar fractures of the humerus in children. J Pediatr Orthop. 1982;2(5):539-546. Level IV. Classic study defining the normal carrying angle and Baumann angle, and showing cubitus varus is usually cosmetic. 10. DeRosa GP, Graziano GP. A new osteotomy for cubitus varus. Clin Orthop Relat Res. 1988;(236):160-165. Level IV. Step-cut osteotomy providing a large contact area and inherent stability without internal fixation.