import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Pierces lateral intermuscular septum 10-12cm proximal to lateral epicondyle, spirals anteriorly between brachialis and brachioradialis in spiral groove. **Protection**: Early identification during lateral approach, subperiosteal dissection, gentle retraction with Hohmann retractors, avoid excessive cautery near nerve course. **Location**: Branches from radial nerve at radiocapitellar joint level, penetrates supinator muscle 4-5cm distal to lateral epicondyle. **Protection**: Avoid distal dissection beyond lateral epicondyle level, stay subperiosteal on lateral supracondylar ridge, minimize retraction of brachioradialis. **Location**: Posterior to medial epicondyle in cubital tunnel, runs in groove between medial epicondyle and olecranon process (relevant if medial approach used). **Protection**: Stay anterior to medial intermuscular septum on medial approach, avoid posterior dissection into cubital tunnel, consider transposition if at risk. **Location**: Anterior to distal humerus medially, run together medial to biceps tendon and brachialis in antecubital fossa. **Protection**: Stay posterior and lateral during exposure, avoid anterior dissection beyond supracondylar ridge, protect with medial Hohmann retractor. **Location**: Terminal sensory branch of musculocutaneous nerve, emerges between biceps and brachialis laterally, crosses surgical field superficially. **Protection**: Identify during subcutaneous dissection, gentle retraction rather than division to prevent lateral forearm numbness. ## Primary Indications **Cosmetic Deformity** - Neutral or negative carrying angle (normally 5-15° valgus) - Visible gunstock deformity with arm extended - Parental/patient concern regarding appearance - Significant asymmetry compared to contralateral side (typically >15° difference) **Timing Requirements** - Minimum 2 years post-injury to assess remodeling potential - Most perform between ages 6-12 years before skeletal maturity - No upper age limit if symptoms warrant correction - Allow time for spontaneous improvement (limited in cubitus varus unlike other deformities) **Functional Prerequisites** - Near full elbow range of motion (functional arc 30-130°) - No significant stiffness or contracture - Stable elbow without instability - Good skin condition at proposed incision site ## Relative Indications - Posterolateral rotatory instability (rare complication) - Ulnar nerve symptoms from altered cubital tunnel mechanics - Functional limitation from deformity (unusual) - Progressive deformity despite skeletal maturity ## Contraindications **Absolute** - Active infection at surgical site - Severe elbow stiffness (arc <60°) - osteotomy will worsen - Vascular compromise or prior vascular injury - Skeletal dysplasia with abnormal bone quality **Relative** - Age <5 years (some remodeling potential remains) - Minimal deformity (<10° varus) - Patient/family expectations unrealistic - Medical comorbidities increasing surgical risk - Poor compliance expected for post-operative rehabilitation **Critical Exam Point**: Cubitus varus does NOT spontaneously remodel significantly after age 2-3 years, unlike many paediatric fractures. The triplanar deformity (varus + internal rotation + hyperextension) persists and may even appear worse with growth. This justifies surgical correction despite being primarily cosmetic. ## Clinical Evaluation **Deformity Assessment** - Carrying angle measurement with both elbows fully extended (compare to contralateral) - Assess triplanar components: varus (coronal), internal rotation (axial), hyperextension (sagittal) - Range of motion documentation (flexion, extension, pronation, supination) - Cubital tunnel examination for ulnar nerve symptoms (rare but check) - Skin assessment for scars from prior surgery or injury **Neurovascular Examination** - Radial nerve: wrist extension, thumb extension, finger MCP extension - Median nerve: thumb opposition, sensation index/middle fingers - Ulnar nerve: finger abduction/adduction, sensation ring/little fingers - Anterior interosseous nerve: thumb IP flexion, index DIP flexion (OK sign) - Posterior interosseous nerve: finger MCP extension with wrist flexed - Vascular: radial/ulnar pulses, capillary refill, Allen test if concern ## Radiographic Planning **Essential Imaging** - Bilateral AP radiographs: long cassette with both elbows fully extended for comparison - True lateral radiographs: elbow 90° flexion to assess sagittal plane - Contralateral normal elbow for template comparison - Consider CT scan for complex three-dimensional deformity planning **Key Measurements** 1. **Baumann Angle** (normal 64-81°) - Angle between humeral shaft axis and lateral condyle physis line - Decreased in cubitus varus (<64°) - Most reliable measurement for varus deformity 2. **Carrying Angle** (normal 5-15° valgus) - Angle between humeral and forearm axes - Neutral or negative in cubitus varus (0° to -30°) - Clinical correlation important as radiographic measurement variable 3. **Humerus-Elbow-Wrist Angle** - Overall alignment from shoulder to wrist - Accounts for combined elbow and wrist alignment 4. **Lateral View Assessment** - Anterior humeral line (normally through middle third of capitellum) - Extension deformity component (if line passes posterior to capitellum) **Templating Process** - Trace affected side radiograph on acetate - Trace contralateral normal for comparison - Mark proposed osteotomy site (2-3cm proximal to olecranon fossa) - Calculate wedge size needed: 1mm base width ≈ 1° correction - Plan for slight overcorrection (5° valgus acceptable) - Template fixation method (K-wires vs plate position) **Measurement Pitfall**: Carrying angle measurement on radiographs is notoriously unreliable due to positioning variability and inability to fully extend elbow with severe deformity. Clinical assessment with elbows extended comparing to contralateral side is most practical. Baumann angle is more reproducible and should be primary measurement for surgical planning. **Patient Position** - Supine on operating table - Radiolucent arm board extended at 90° to table - Affected arm positioned on arm board with shoulder abducted 70-90° - Ensure C-arm can access for AP and lateral fluoroscopy - Consider sandbag under ipsilateral shoulder for stability **Preparation and Draping** - Entire upper extremity prepared from shoulder to fingertips - Include surgical field from axilla to hand circumferentially - Waterproof drapes isolating operative field - Limb exsanguinated with elevation (tourniquet optional but helpful) - Sterile tourniquet on upper arm if used (typically 200-250mmHg) **Surgical Approach Decision** **Lateral Approach** (Most Common) - Between brachioradialis (anterior) and triceps (posterior) - Advantages: familiar anatomy, radial nerve can be identified/protected - Disadvantages: scar more visible, higher radial nerve risk - Preferred by most surgeons due to familiarity **Medial Approach** (Alternative) - Anterior to medial intermuscular septum - Advantages: better cosmetic scar (inner arm), lower radial nerve risk - Disadvantages: ulnar nerve at risk if technique poor - Consider in females where cosmesis paramount Tourniquet use is optional but helpful for hemostasis. If used: (1) Apply sterile tourniquet proximally on upper arm, (2) Inflate to 200-250mmHg after exsanguination, (3) Limit tourniquet time to <90 minutes, (4) MUST release before closure to verify neurovascular integrity and achieve hemostasis before closing wound. Many surgeons prefer no tourniquet to allow continuous neurovascular monitoring. ### Step 1: Skin Incision and Superficial Dissection **Lateral Approach Incision** - 8-10cm longitudinal incision along lateral supracondylar ridge - Center incision 2-3cm proximal to lateral epicondyle - Curve slightly posteriorly proximally, anteriorly distally - Incise skin and subcutaneous tissue with cutting diathermy **Superficial Structures** - Identify and protect lateral antebrachial cutaneous nerve (terminal branch of musculocutaneous) - Emerges between biceps and brachialis, crosses field superficially - Gentle retraction preferable to division (prevents lateral forearm numbness) - Ligate perforating vessels with bipolar cautery **Anatomical Pearl**: The lateral antebrachial cutaneous nerve is frequently encountered and at risk during superficial dissection. Division causes bothersome numbness over lateral forearm which patients may find more troublesome than original deformity. Identify early, mobilize gently, and preserve whenever possible. - Lateral antebrachial cutaneous nerve injury (10-15%): identify in subcutaneous fat between biceps and brachialis, gentle retraction not division - Excessive superficial dissection: stay focused on supracondylar ridge, avoid distal extension toward radiocapitellar joint where PIN vulnerable ### Step 2: Intermuscular Interval and Deep Exposure **Identify Interval** - Develop plane between brachioradialis anteriorly and triceps posteriorly - Brachioradialis identified by muscle bulk on anterior aspect of lateral supracondylar ridge - Triceps lateral head inserts on posterior aspect of distal humerus - Bluntly separate muscles in relatively avascular plane **Deep Dissection** - Radial nerve pierces lateral intermuscular septum 10-12cm proximal to lateral epicondyle - At osteotomy level (2-3cm proximal to epicondyle) nerve already anterior between brachialis and brachioradialis - Can identify nerve by palpating between muscles proximal to osteotomy site - Once identified, protect throughout with gentle retraction **Exposure of Distal Humerus** - Identify lateral supracondylar ridge (bony landmark) - Elevate brachioradialis origin subperiosteally from lateral ridge - Elevate triceps lateral head from posterior distal humerus - Expose circumference of humerus 2-3cm proximal to olecranon fossa **Radial Nerve Safety**: The radial nerve is ANTERIOR to the osteotomy site having already pierced the lateral intermuscular septum more proximally. Subperiosteal elevation at the metaphyseal osteotomy level keeps dissection deep to the nerve plane. The nerve is most at risk from retractor pressure or excessive traction during bone manipulation, not from saw cuts if proper subperiosteal technique used. - Radial nerve injury (2-5%): identify nerve course between brachialis and brachioradialis, use Hohmann retractors subperiosteally, avoid excessive retraction force - Posterior interosseous nerve (PIN): avoid distal dissection beyond lateral epicondyle level where PIN penetrates supinator - Excessive periosteal stripping: limit to osteotomy site to preserve blood supply ### Step 3: Osteotomy Planning and Marking **Identify Osteotomy Level** - 2-3cm proximal to olecranon fossa (supracondylar metaphyseal region) - Distal enough for good correction leverage, proximal enough to avoid joint - Use ruler or marking to ensure adequate distance from olecranon fossa - Confirm level with fluoroscopy (should be entirely metaphyseal, no physis) **Mark Wedge Using Template** - Transfer preoperative template measurements to bone - Lateral closing wedge: apex medial (intact), base lateral (removed) - Mark proximal cut line: lateral cortex angling distally-medially toward apex - Mark distal cut line: lateral cortex angling proximally-medially toward same apex - Base width (lateral) = correction needed (1mm ≈ 1° correction) - Typical deformity 15° requires 15mm lateral base width **Reference K-wires** - Insert 2.0mm K-wire parallel to joint line distal to planned osteotomy - Insert second K-wire proximal to osteotomy aligned with humeral shaft - These reference wires help assess correction intraoperatively - Can measure angle between wires before and after osteotomy **Correction Calculation**: Rule of thumb: 1mm lateral wedge base = 1° varus correction. For 15° cubitus varus deformity aiming for 5° valgus final result, need 20° correction, therefore 20mm lateral wedge base. Always verify with preoperative templating and contralateral comparison. Slight overcorrection (5° valgus) is acceptable and allows for some settling/loss of correction. - Undercorrection (most common error): err on side of more correction, slight overcorrection acceptable - Osteotomy too distal: entering olecranon fossa risks intra-articular fracture, keep 2-3cm proximal minimum - Inadequate wedge marking: use template measurements, marking pen or methylene blue for clear visualization ### Step 4: Perform Lateral Closing Wedge Osteotomy **Protect Soft Tissues** - Place Hohmann retractors subperiosteally around circumference of humerus - Anterior retractor protects brachialis and neurovascular structures - Posterior retractor protects triceps - Medial retractor protects soft tissues from saw blade during osteotomy **Osteotomy Technique** - Oscillating saw with copious irrigation to prevent thermal necrosis - First cut: proximal limb from lateral cortex angling distally-medially to apex - Incomplete medial cortex with first cut (leave hinge) - Second cut: distal limb from lateral cortex angling proximally-medially to same apex - Again leave medial cortex intact as hinge - Remove wedge of bone (save for autograft if needed) **Preserve Medial Hinge** - Medial cortex serves as hinge for stable closure - Complete both saw cuts to within 2-3mm of medial cortex - Gently complete medial cortex with narrow osteotome if needed - OR leave as greenstick to compress when closing wedge - Intact medial hinge provides inherent stability and compression **Medial Cortex Hinge Technique**: The medial cortex hinge is the key to stability in lateral closing wedge osteotomy. Preserve it by incomplete saw cuts stopping 2-3mm from medial cortex, then gently fracture with osteotome or compress as greenstick when closing wedge. This creates compression at osteotomy site enhancing healing. If accidentally completely transected, osteotomy becomes unstable requiring more secure fixation (plate rather than K-wires). - Complete medial cortex transection: creates unstable osteotomy, requires plate fixation, higher non-union risk - Saw thermal necrosis: copious irrigation essential, keep saw moving, avoid prolonged bone contact - Neurovascular injury from saw: retractors must protect soft tissues, especially medially where neurovascular bundle anterior - Intra-articular extension: stay 2-3cm proximal to olecranon fossa, verify with fluoroscopy ### Step 5: Close Osteotomy and Verify Correction **Wedge Closure** - Apply medial-to-lateral compression force to close wedge - Hinges on preserved medial cortex (greenstick or incomplete) - Lateral cortices should approximate with bone-to-bone contact - Remove any interposed soft tissue preventing closure - Hold compression manually while checking alignment **Clinical Verification** - Assess carrying angle compared to contralateral elbow - Should achieve 5-10° valgus (slight overcorrection acceptable) - Palpate alignment of distal humerus with proximal shaft - Check for rotational deformity (align distal fragment with proximal) **Fluoroscopic Verification** - AP view: measure Baumann angle (should be 64-81°, symmetric to contralateral) - AP view: measure carrying angle (target 5-10° valgus) - Lateral view: check anterior humeral line (through middle third capitellum) - Oblique views: rule out rotational malalignment - Compare to preoperative and contralateral radiographs **Intraoperative Assessment Priority**: Clinical assessment of carrying angle comparing to contralateral side is actually MORE reliable than fluoroscopic measurements due to positioning variability. With elbows extended and forearms supinated, carrying angles should be within 5° of each other. Fluoroscopy confirms there's no gross error and documents correction but trust clinical comparison for final judgement. - Undercorrection from inadequate wedge: if recognized, can remove more bone and re-close before fixation - Overcorrection to excessive valgus (greater than 15°): worse than undercorrection due to tardy ulnar nerve palsy risk, difficult to reverse - Rotational malalignment: ensure distal fragment not internally or externally rotated relative to shaft, check alignment of epicondylar axis - Loss of reduction during fixation: maintain compression while applying fixation ### Step 6: Internal Fixation **Fixation Options** **Option 1: Crossed K-wires (Most Common)** - 2-3 smooth 2.0mm K-wires from lateral cortex - First wire: oblique from lateral epicondylar region across osteotomy into medial proximal cortex - Second wire: oblique from lateral supracondylar ridge across osteotomy into medial cortex (crosses first wire) - Optional third wire for additional stability - Leave wires percutaneous for easy removal (cut and bend outside skin) - Advantages: simple, adequate stability for metaphyseal bone, easy removal - Disadvantages: pin site care required, migration risk (1-2%) **Option 2: Plate and Screws** - Small plate (3.5mm reconstruction or 2.7mm paediatric plate) - Applied to lateral cortex as tension band - Typically 6-8 hole plate with 3-4 screws proximal, 3-4 screws distal - Compress osteotomy site with plate application - Advantages: more stable, allows earlier mobilization, no pin care - Disadvantages: more soft tissue dissection, requires hardware removal later, more expensive **Fixation Technique** - Maintain compression at osteotomy site during fixation application - Ensure wires/screws engage far cortex for stability - Verify fixation position with fluoroscopy (AP and lateral) - Check no wire/screw penetration into joint - Assess stability with gentle varus/valgus stress under fluoroscopy **Fixation Selection**: K-wire fixation is usually adequate for lateral closing wedge osteotomy because the medial cortex hinge provides inherent stability and metaphyseal bone heals reliably. Plate fixation is indicated if: (1) medial cortex completely transected (unstable), (2) poor bone quality, (3) desire very early mobilization, (4) complex multiplanar correction requiring secure fixation. Most surgeons use K-wires for simple lateral closing wedge in paediatric patients. - K-wire migration into joint (1-2%): proper technique with bicortical purchase, leave external for removal, warn family about pin care - K-wire migration into neurovascular structures: extremely rare but reported, use smooth wires not threaded, proper bend outside skin - Inadequate fixation: loss of correction if osteotomy unstable and fixation insufficient - Plate prominence: lateral plate may be palpable/irritating, usually requires removal 6-12 months ### Step 7: Neurovascular Verification **Release Tourniquet** - Release tourniquet (if used) before closure - Allows vascular assessment and hemostasis - Minimum 10 minutes for vasospasm to resolve before assessing perfusion **Vascular Assessment** - Palpate radial pulse (should be strong and equal to contralateral) - Assess capillary refill (should be less than 2 seconds) - Check overall limb perfusion, color, temperature - If any concern: ensure no kinking/compression of brachial artery **Neurological Assessment** - **Radial nerve**: wrist extension, thumb extension (EPL), finger MCP extension - **Posterior interosseous nerve**: finger MCP extension with wrist stabilized - **Median nerve**: thumb opposition, thenar muscle bulk - **Anterior interosseous nerve**: thumb IP flexion and index DIP flexion (OK sign) - **Ulnar nerve** (if medial approach): finger abduction/adduction, intrinsic function **Management of Deficit** - Any new deficit: explore nerve to ensure not entrapped or divided - If nerve intact but in continuity injury: likely neuropraxia, observe - If nerve divided: primary repair with microsurgical technique - Document deficit immediately in operative note **Radial Nerve Palsy Presentation**: Most radial nerve injuries from this procedure are neuropraxias (stretch/compression) presenting as wrist drop and weak finger MCP extension. Thumb IP flexion (FPL via AIN) is preserved distinguishing from median nerve injury. Sensation over first dorsal web space may be diminished. Most neuropraxias recover in 3-6 months with observation and splinting. Immediate complete palsy warrants exploration to rule out laceration. - MUST verify neurovascular status before closing: medicolegal and patient safety essential - Document baseline neurological examination in operative note - If deficit present: explore nerve immediately, don't close and hope for best - If vascular compromise: check for arterial kinking, hematoma compression, ensure no tourniquet still inflated ### Step 8: Wound Closure and Dressing **Hemostasis** - Copious irrigation with normal saline (500-1000mL minimum) - Bipolar cautery for small bleeding vessels - Avoid cautery near identified neurovascular structures - Consider small suction drain if significant ooze (1/8 inch hemovac, remove 24 hours) **Layered Closure** - Close periosteum if possible (2-0 Vicryl) - helps stabilize soft tissue envelope - Close deep fascia and muscle (2-0 or 3-0 Vicryl interrupted or running) - Close subcutaneous tissue (3-0 Vicryl buried interrupted) - Skin closure: subcuticular 4-0 Monocryl (absorbable) or interrupted 4-0 Nylon (removed 10-14 days) - Skin adhesive (Dermabond) or Steri-Strips for additional skin edge approximation **Dressing** - Non-adherent dressing (Xeroform or Adaptic) over incision - Sterile gauze padding over wound - Soft roll gauze circumferentially around elbow (not tight) - Apply posterior elbow splint over dressing (next step) - Inadequate hemostasis: hematoma can compress radial nerve causing delayed palsy (1-2%) - Avoid drain if possible to reduce infection risk, but use if significant ooze to prevent hematoma - Prophylactic antibiotics: single dose preoperative (cefazolin 25-50mg/kg) reduces infection risk to <1% ### Step 9: Splint Application **Posterior Elbow Splint Technique** - Apply with elbow at 90° flexion (comfortable position) - Forearm in neutral rotation (thumb pointing up) - Splint extends from upper arm (mid-humeral level) to metacarpal heads - Leave MCP joints free for finger motion - Posterior application (not circumferential initially to allow swelling) **Padding and Molding** - Generous padding with cotton cast padding (3-4 layers minimum) - Extra padding over pressure points: olecranon, medial/lateral epicondyles - Plaster or fiberglass: 8-10 layers of 4-inch splint material - Mold carefully: compress anterior and posterior surfaces gently - Avoid excessive molding pressure over fresh osteotomy site **Secure Splint** - Overwrap with elastic bandage (3-4 inch Ace wrap) - Moderate compression only, not tight - Ensure fingertips visible for neurovascular monitoring - Can apply Velcro straps for security **Splinting vs Casting**: Use posterior splint NOT circumferential cast initially to allow for post-operative swelling. Compartment syndrome is very rare after elbow osteotomy but circumferential cast increases risk. Splint provides adequate immobilization for 1-2 weeks until swelling subsides. Can convert to cast later if needed for patient compliance but most transition directly to removable splint/sling. - Tight splint or circumferential cast: compartment syndrome risk (rare but serious), allow swelling space - Inadequate padding: pressure sores over olecranon or epicondyles - Elbow flexed greater than 90°: can compromise venous drainage and increase swelling - Splint too distal: restricts finger motion increasing stiffness risk ## Recovery Room Protocol **Monitoring** - Neurovascular observations every 15 minutes first hour - Then hourly for 4 hours minimum - Check radial pulse, capillary refill, finger color/temperature - Assess radial nerve function (wrist extension, finger MCP extension) - Document pain scores and response to analgesia **Warning Signs** - Increasing pain unresponsive to analgesia (compartment syndrome concern) - Diminished or absent radial pulse - Capillary refill greater than 3 seconds - Finger stiffness, swelling, coolness - New neurological deficit - Any concern: remove splint immediately and examine **Admission vs Discharge** - **Admit overnight if**: young child (<5 years), significant swelling, social concerns, distance from hospital greater than 1 hour - **Same day discharge if**: older child/adolescent, minimal swelling, reliable family, close to hospital - Either way: strict neurovascular precautions, written warning signs, clear contact instructions ## Pain Management **Multimodal Analgesia** - Regular paracetamol (15mg/kg every 6 hours, maximum 4g/24hr) - NSAID (ibuprofen 10mg/kg every 8 hours) if no contraindication - Opioid for breakthrough (oxycodone 0.1-0.2mg/kg every 4-6 hours PRN) - Ice therapy (20 minutes on, 20 minutes off, protect skin from direct ice contact) **Elevation** - Arm elevated on pillows above heart level - Reduces swelling and pain - Encourage hand/finger exercises to pump swelling Although rare after elbow osteotomy, compartment syndrome is devastating if missed. Classic 5 P's: Pain (disproportionate, increasing), Pressure (tense compartments), Paresthesia (nerve distribution), Pallor (late sign), Pulselessness (very late, often absent). PAIN out of proportion to injury unresponsive to analgesia is earliest and most reliable sign. Low threshold to remove splint and examine. If concern persists: measure compartment pressures and proceed to forearm fasciotomy if elevated (delta pressure <30mmHg). ## Week 1-2: Wound Check and Splint Transition **First Visit (7-10 days)** - Remove dressing, inspect wound - Remove sutures if non-absorbable used (alternatively 14 days) - Wound care: keep clean and dry, watch for infection signs - Radiographs: AP and lateral to assess fixation position - Remove posterior splint, transition to removable splint or sling for comfort **Begin Active Range of Motion** - Active assisted ROM exercises immediately after splint removal - Gravity-assisted flexion and extension - Active supination and pronation - NO passive stretching (risks fixation failure and loss of correction) - Gentle active use for activities of daily living **Restrictions** - No heavy lifting (greater than 2kg/5 pounds) - No contact sports or rough play - No passive stretching or forced motion - Removable splint for protection during sleep and outdoor activities ## Week 6: Callus Assessment **Clinical Evaluation** - ROM measurement (expect 80-90% normal by 6 weeks) - Wound healing assessment - Neurovascular examination **Radiographs** - AP and lateral views - Assess for callus formation (should be visible by 4-6 weeks in children) - Verify maintained alignment (no loss of correction) - If K-wires used: ready for removal if callus adequate **K-wire Removal** - If adequate callus present (bridging 3/4 cortices) - Can be done in clinic with local anesthesia in older children/adolescents - Alternatively brief sedation or general anesthesia in younger children - Cut wires at skin level and remove with needle-nose pliers or wire cutter - Apply dressing, continue ROM exercises ## Week 12: Union Assessment and Return to Activities **Clinical Evaluation** - Should have full or near-full ROM (functional arc minimum) - Assess carrying angle correction (compare to contralateral) - No tenderness over osteotomy site **Radiographs** - Solid union expected by 12 weeks (cortical bridging all 4 cortices) - Maintained correction of carrying angle - Remodeling of lateral cortex prominence **Activity Progression** - Return to full activities including contact sports if union solid - Strengthen with progressive resistance exercises - Unrestricted use ## Month 6-12: Hardware Removal (if plate used) **Plate Removal Indications** - Routine: 6-12 months after solid union confirmed - Earlier if symptomatic (plate prominence, irritation) - Later if patient asymptomatic and wants to avoid another surgery **Plate Removal Procedure** - Through same incision - Less dissection than original surgery - Remove plate and screws under direct vision - Protect radial nerve (scarred from first surgery) - Similar post-operative protocol (splint 1-2 weeks, ROM) ## Long-term Follow-up to Skeletal Maturity **Annual Visits** - Clinical carrying angle assessment - Radiographs every 1-2 years - Monitor for recurrence (rare, typically only if premature physeal closure) - Monitor for late complications (ulnar nerve symptoms if overcorrected to valgus) **Expected Outcomes** - Excellent cosmetic correction: carrying angle within 5° of contralateral (85-90% patients) - Full elbow ROM: 95% achieve functional arc (30-130°) - High satisfaction: 85-95% patients/families satisfied with correction - Low complication rate: 5-10% overall complications, mostly minor **Early Mobilization Importance**: Historical protocols used prolonged immobilization (6 weeks) which led to significant elbow stiffness. Current evidence supports early active ROM starting at 1-2 weeks once wound healed. Metaphyseal bone heals reliably even with early motion. Key is distinction between active (patient-controlled) and passive (therapist-forced) ROM - active is safe and beneficial, passive risks fixation failure and should be avoided until solid union at 8-12 weeks. ## Alternative Osteotomy Techniques **Lateral Closing Wedge** (Most Common - described above) - Advantages: simple, stable medial hinge, familiar anatomy, reliable correction - Disadvantages: lateral scar, lateral prominence, shortens humerus slightly (usually insignificant) - Best for: routine cubitus varus correction in most patients **Medial Closing Wedge** - Remove medial bone wedge, lateral cortex hinge, lateral approach same - Advantages: corrects valgus deformity, less radial nerve risk (working medially), less lateral prominence - Disadvantages: ulnar nerve at risk, less familiar anatomy, less stable hinge - Best for: cubitus valgus correction, revision cases with lateral scarring **Lateral Opening Wedge** - Osteotomy with gap opening laterally, bone graft to fill wedge - Advantages: no shortening, potentially more precise correction, medial hinge intact - Disadvantages: requires bone graft (iliac crest donor site), delayed union risk, more complex - Best for: need to maintain length, combined with other procedures where harvesting graft anyway **Dome (Curved) Osteotomy** - Curved osteotomy rather than wedge, allows multiplanar correction - Advantages: can address triplanar deformity (varus + rotation + extension) simultaneously, more stable than wedge - Disadvantages: technically demanding, special instruments helpful, longer surgery time - Best for: complex three-dimensional deformities, revision cases **Step-Cut Osteotomy** - Multiple small steps creating overall correction - Advantages: very stable inherently, large contact surface area, can address rotation - Disadvantages: technically demanding, requires careful planning and execution - Best for: revision cases, poor bone quality, need for very stable fixation ## Medial Approach Technique **When to Consider** - Female patients where cosmesis paramount (medial scar less visible) - Revision cases with lateral scarring or radial nerve concerns - Combined procedures requiring medial exposure (e.g., ulnar nerve transposition) **Approach Details** - Incision: 8-10cm over medial supracondylar area anterior to medial epicondyle - Identify and protect medial antebrachial cutaneous nerve superficially - Interval: anterior to medial intermuscular septum (stay anterior to avoid ulnar nerve) - Elevate brachialis and pronator teres origins from medial distal humerus - Perform lateral closing wedge osteotomy from medial side (working across) - OR perform medial opening/closing wedge depending on deformity **Advantages of Medial Approach** - Better cosmetic scar (inner arm less visible) - Lower radial nerve risk (working from medial side) - Direct access for ulnar nerve assessment/transposition if needed **Disadvantages of Medial Approach** - Less familiar anatomy for most surgeons - Ulnar nerve at risk if technique poor (go posterior inadvertently) - More difficult access to lateral cortex for standard lateral closing wedge **Triplanar Deformity Consideration**: Cubitus varus is NOT just varus in coronal plane. It's triplanar: (1) Varus angulation (coronal), (2) Internal rotation deformity (axial), (3) Hyperextension (sagittal). Simple lateral closing wedge primarily corrects coronal varus. For complete correction of all three planes, consider dome osteotomy or step-cut which allow simultaneous multiplanar correction. In practice, most patients satisfied with coronal correction alone as rotational and sagittal components usually mild and improve secondarily with varus correction. ## Age-Related Factors **Younger Children (5-8 years)** - More remodeling potential (slight residual varus may improve) - Better bone healing (faster union, usually 6-8 weeks) - Less cooperation with post-operative protocols (may need longer immobilization) - Smaller instruments needed (2.7mm plate, 2.0mm K-wires) - Lower anesthetic risk generally - Family compliance critical (post-operative care, physiotherapy) **Older Children/Adolescents (9-15 years)** - Less remodeling potential (need accurate correction) - Still excellent bone healing (8-12 weeks typically) - Better cooperation with ROM exercises and restrictions - Can use adult-size instruments (3.5mm plate, 2.0-2.5mm K-wires) - K-wire removal in clinic with local anesthesia often feasible - More aware of cosmetic outcome, may have input on scar placement ## Growth Plate Considerations **Distal Humeral Physis** - Osteotomy is supracondylar (metaphyseal), proximal to physis - Should NOT cross physis with osteotomy or fixation - Verify on fluoroscopy that fixation does not penetrate physis - Growth disturbance very rare if physis avoided - If inadvertent physeal injury: monitor for growth arrest **Remodeling Potential** - Cubitus varus does NOT remodel significantly after age 2-3 years - Unlike other paediatric fractures, spontaneous correction minimal - Triplanar deformity particularly resistant to remodeling - Waiting for remodeling is NOT appropriate management - However slight undercorrection in younger child (age 5-7) may improve slightly ## Family Education and Expectations **Preoperative Counseling** - Explain primarily cosmetic procedure (functional ROM usually preserved) - Realistic expectations: aiming for symmetry within 5° of contralateral - Discuss risks especially radial nerve injury (2-5% temporary) - Explain post-operative protocol (splint, ROM, activity restrictions) - Hardware removal required at 6-12 months (second anesthetic/procedure) - Small risk residual deformity may need revision **Compliance Requirements** - Strict activity restrictions for 12 weeks (no contact sports, rough play) - Daily ROM exercises once splint removed (family must supervise) - Pin site care if K-wires (daily cleaning, watch for infection) - Multiple follow-up visits required (weeks 1, 6, 12, then longer intervals) - Long-term follow-up to skeletal maturity recommended **Timing of Surgery Decision**: Optimal timing is age 6-12 years. Earlier than 5 years: some minimal remodeling potential remains, compliance issues, smaller anatomy more challenging. Later than 12 years (adolescent): less concerning cosmetically, patient can decide for themselves, risk of skeletal maturity before full follow-up. Most common age at surgery is 7-10 years when deformity established, patient stable for anesthesia, enough growth remaining to observe final result, and family compliance feasible. ## Indications for Revision Osteotomy **Undercorrection** (Most Common) - Significant residual varus (≥10-15° from contralateral) - Patient/family dissatisfaction with cosmetic result - Ensure adequate time post-initial surgery (minimum 6 months, ideally 12 months for complete remodeling) **Overcorrection** - Excessive valgus (>20°) causing cosmetic or functional concern - Tardy ulnar nerve symptoms developing - Less common than undercorrection but more problematic **Recurrence** - Loss of correction over time (very rare) - Usually from growth disturbance or premature physeal closure - Requires investigation for underlying cause ## Technical Considerations for Revision **Challenges** - Scar tissue makes dissection more difficult - Anatomy distorted from prior surgery - Radial nerve may be scarred in lateral approach zone - Bone quality at prior osteotomy site may be sclerotic - Fixation may be more difficult in previously operated area **Solutions** - Consider different approach (medial if lateral used initially, or vice versa) - Meticulous dissection expecting nerve in scar tissue - May need osteotomy at different level (more proximal or distal) - Consider alternative osteotomy type (dome or step-cut for more stable fixation) - Plan for plate fixation rather than K-wires (more secure in revision) - Consider bone graft if concern about healing in revision setting **Expected Outcomes** - Generally good if adequate correction achieved - Higher complication rate than primary (15-20% vs 5-10%) - Radial nerve injury risk higher in revision (5-10% vs 2-5%) - Patient/family satisfaction still high if deformity corrected **Prevention Better Than Revision**: Best strategy is accurate correction at initial surgery to avoid revision. Use preoperative templating, intraoperative measurement, fluoroscopic verification, and clinical comparison to contralateral elbow. Err on side of slight overcorrection (5° valgus) rather than undercorrection, as mild valgus cosmetically acceptable and functionally benign, whereas residual varus defeats purpose of surgery and may require revision. ## References 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. doi:10.2106/JBJS.L.01622 - Level of evidence: IV (case series). Demonstrates three-dimensional CT-based planning and custom cutting guides improve accuracy of correction in cubitus varus osteotomy. 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. - Level of evidence: IV (case series). Classic study showing lateral closing wedge osteotomy provides excellent long-term cosmetic correction with high patient satisfaction (90%) and low complication rate. 3. **Karatosun V, Alici E, Günal I, Çakmak M, Işik 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. doi:10.1302/0301-620x.82b7.10151 - Level of evidence: III (comparative study). Demonstrates malunion with varus is primary cause of cubitus varus, occurs in 10-15% of supracondylar fractures, 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 of evidence: IV (case series). Shows corrective osteotomy achieves good correction but 15-20% have residual deformity from inadequate initial correction, emphasizing need for accurate preoperative planning. 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 of evidence: IV (case series). Describes lateral condylar prominence as common finding (5-10%) after lateral closing wedge, usually remodels but may require resection if cosmetically concerning. 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. - Level of evidence: IV (case series). Demonstrates lateral closing wedge with medial cortical hinge provides stable fixation, reliable union (98%), and good cosmetic result (85% excellent/good). 7. **Kim HT, Lee JS, Yoo CI.** Management of cubitus varus and valgus. *J Bone Joint Surg Am.* 2005;87(4):771-780. doi:10.2106/JBJS.D.02413 - Level of evidence: V (expert opinion/review). Comprehensive review of cubitus varus pathoanatomy (triplanar deformity), treatment options (lateral closing wedge, dome, step-cut), and outcomes. 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 of evidence: IV (case series). Describes dome osteotomy technique for simultaneous correction of triplanar deformity (varus + internal rotation + extension), more complex but addresses all deformity components. 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 of evidence: IV (case series). Classic study defining normal carrying angle (5-10° valgus males, 10-15° females), Baumann angle (64-81°), and demonstrating cubitus varus is cosmetic problem rarely causing functional issues. 10. **DeRosa GP, Graziano GP.** A new osteotomy for cubitus varus. *Clin Orthop Relat Res.* 1988;(236):160-165. - Level of evidence: IV (technical report). Describes step-cut osteotomy providing large contact surface area, inherent stability without internal fixation, useful for revision cases or poor bone quality.

Supracondylar Humeral Osteotomy for Cubitus Varus

Supracondylar Humeral Osteotomy for Cubitus Varus