DOI: 10.7860/JCDR/2017/24345.

9551
Original Article

Management of Cubitus Varus

Orthopaedics Section
Deformity in Children by
Closed Dome Osteotomy

PARTAP SINGH VERKA1, UJJWAL KEJARIWAL2, BIJENDRA SINGH3

ABSTRACT appropriate pre operative assessment, closed dome osteotomy

Introduction: Supracondylar fractures are the most common was done and post operatively X-ray of patients was taken and
elbow injuries in skeletally immature children between 5-10 carrying angle and Lateral Condylar Prominence Index (LCPI)
years of age and cubitus varus deformity is the most common were calculated. Patients were re-assessed at complete union and
late complication. Cubitus varus or bow elbow or gunstock results were calculated as per Mitchell and Adams criteria.
deformity is the result of malunion occurring as a complication of Results: In our study of 25 patients, 68% were males, 32% were
supracondylar fracture of the humerus. Various type of corrective females. Majority (84%) of patients were in the age group of 5-10
osteotomies are used of which lateral closed wedge French years. Carrying angle post operatively was 0-10° valgus in 64%
osteotomy is commomly used which has its own complications of patients while 36% had 10-20° valgus. LCPI changed post
like lateral condylar prominence, unsightful scar and limitation operatively ranging from +5.0% to -10.7%, average -2.75%.
of movement. Closed dome osteotomy is a technique which Decrease in LCPI had better cosmetic appearance. Range of
overcomes these complications. This surgery is done with simple motion post operatively increased or remained same as previous
readily available instruments in the orthopaedic operation theatre full motion in 84% of the patients. Union occurred in all patients
with no special requirements for instrumentation. by eight weeks. Few complications were seen. Results according
Aim: This study was done to study the results of closed dome to Mitchell and Adams criteria were excellent in 88% and good in
osteotomy for correction of cubitus varus deformity, after 12%; while no poor results were recorded.
malunited supracondylar fracture of humerus in children. Conclusion: The results obtained in our study concluded
Materials and Methods: This study included 25 children of either that closed dome osteotomy is safe and effective treatment
sex with malunited supracondylar fracture of distal humerus having for the correction of cubitus varus deformity with few minor
cubitus varus deformity admitted in orthopaedics department. After complications.

Keywords: Deformity correction, Paediatric osteotomy, Supracondylar fracture of humerus

Introduction maintenance of the reduction which can be done by immobilization,

Cubitus varus deformity is the most common late complication closed percutaneous pinning or internal fixation.
after supracondylar fracture of distal humerus in children, incidence Cubitus varus or bow elbow or gunstock deformity is the result of
varying from 4% to 58% [1,2]. malunion occurring as a complication of supracondylar fracture of
Elbow injuries are common in skeletally immature children, between the humerus. It occurs in only the extension type of supracondylar
5-10 years of age [3,4]. Metaphyseal area of the distal humerus is fracture of the humerus, causing a reduction or loss of the carrying
the weakest region around the elbow, so supracondylar fractures angle.
are the most common elbow injuries. Also, the frequent falls in small Various aetiologies have been suggested. The usual aetiology of
children while playing, cycling or fall inside the house from bed, cubitus varus deformity is malunion of distal humeral fragment rather
sofa has added to the increase in incidence. Non dominant side than growth disturbance [7]. Osteonecrosis with or without growth
and boys have a more predilection to such injuries than dominant arrest is rare but a very important cause of varus deformity [8].
side and girls. Associated vascular injuries in 1% of the cases and Cubitus varus deformity has no tendency for spontaneous correction
nerve injuries involving median and radial nerve in atleast 7% of the but it always has to be corrected. Treatment options include:
cases adds to the concern [5,6]. Increased ligamentous laxity also
correlates with the occurrence of supracondylar fracture. Fractures (a) Observation with expectant remodelling: Not
in this region need aggressive treatment and proper rehabilitation appropriate because although hyperextension may
protocol to gain better functional outcome. Different methods have remodel to some degree in a young child, in an older
been used for the treatment of supracondylar fractures. Most can child little remodelling occurs even in the joint’s plane of
be reduced by manipulation and closed reduction, some require motion. Hence, it is not recommended.
open reduction. Adequate reduction is assessed fluoroscopically by (b) Hemiepiphysiodesis and growth alteration: It is used
Baumann’s angle, formed by the physeal line between the lateral to prevent cubitus varus deformity in a patient with
condyle and the line touching distal humeral articular margins and medial growth arrest and progressive deformity, rather
perpendicular with the long axis of the humerus. Difficulty arises in than correcting it. It has no role in a child with a normal
physis.

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www.jcdr.net Partap Singh Verka et al., Management of Cubitus Varus Deformity in Children by Closed Dome Osteotomy

(c) Corrective Osteotomy: Osteotomy is the only way to the parent’s concern for cosmetic appearance of elbow.
correct a cubitus varus deformity with a high probability The exclusion criteria included parent’s/patient’s refusal for surgery
of success. Options include; and age of patient more than 15 years.
• Medial open wedge osteotomy, which causes lengthening An informed written consent of the parents was obtained before
of medial aspect of humerus causing stretching of ulnar inclusion in this study. Approval from the Ethical Committee was
nerve [9]. taken for the study and inclusion of patients, in accordance with the
• Lateral closing wedge osteotomy with or without Helsinki Declaration of 1975 (revised 2000). 
simultaneous correction of rotation, also known as French Clinical history, general physical examination and local examination
osteotomy [7,10]. were performed. Patient was investigated for operative anaesthetic
• Step cut osteotomy. purposes. Supportive and prophylactic therapy in form of
• Arch osteotomy [11]. physiotherapy was given.
• Pentalateral osteotomy [12].
Preoperative Assessment
• Oblique osteotomy with derotation. Anterio-posterior and lateral radiographs of elbow were taken with
• Dome osteotomy [13]. elbow in full extension and forearm in full supination [Table/Fig-2].
The various osteotomies performed can be fixed using metal plates, The humerus-elbow-wrist angle was measured on both sides using
stainless steel wires, screws and staples. Unstable internal fixation the Oppenheim method and the angle of correction was estimated
allows the osteotomy fragment to slip into a varus position in a [Table/Fig-3]. The LCPI was calculated on the affected side as
number of patients [14]. described by Wong HK [17], using the formula {LCPI= (AB-BC)/
AC*100}, where B is the crosslink between a line connecting the
It has been found that dome osteotomy provides maximum stability
lateral prominence A, the medial prominence C and the longitudional
of maintaining the correction, avoids lateral condyle becoming more
mid-humeral axis [Table/Fig-4]. Range of motion of the affected
prominent and its scar is more cosmetically acceptable. [Table/Fig-1]
elbow was noted, along with complaints of cosmesis, pain and loss
shows the comparison between lateral closed wedge osteotomy
of motor power and sensation.
and dome osteotomy in terms of lateral condyle prominence.
The technique of dome osteotomy was initially mentioned by
Preoperative Plan for Osteotomy
Tachdijan but he gave only theoretical description of the technique
The mid humeral axis was drawn over the Anterio-posterior (AP)
[13]. This was followed by Higaki T and Ikuta Y who reported this
radiograph of the affected side. A point (point O) was marked where
procedure [15].
this axis cut the olecranon fossa, another point (point A) was marked
Kirschner wire fixation or plate fixation can be used to hold the at the junction of lateral condylar epiphysis with distal humerus. Point
fragments and elbow immobilized post operatively with a POP O and point A were joined. Then the angle of correction making OA
cast for three-four weeks. If the fragments can be stabilized with a as base was drawn. Another point was made where this angle cut
rigid fixation, early post operative movements can be gained, thus the distal humerus (point B). Now O becomes the centre of the
giving a hope of good range of movements and excellent functional dome and OB the radius of the dome. With this radius a dome was
outcome. drawn. The arc of the dome was the proposed site of osteotomy as
Closed dome osteotomy has various advantages like a cosmetically shown in [Table/Fig-5].
better scar due to minimally invasive procedure, no lateral prominence
of elbow, no lateral translation of humero-ulnar axis, all rotational Surgical Technique
and angulational deformities can be corrected simultaneously and All the necessary aseptic precautions and preparations were done
early mobilization and rehabilitation [16]. for the surgery. A Moore’s pin was passed from posterior to anterior
This study was done to evaluate the results of closed dome just proximal to olecranon fossa and perpendicular to the coronal
osteotomy for correction of cubitus varus deformity, after malunited plane of humerus. A stab incision was given at the margins of
supracondylar fracture of humerus in children. humerus and periosteum elevated. Multiple holes in a dome shape

MATERIALS AND METHODS

The present prospective study consisted of 25 cases of either sex
in children with malunited supracondylar fracture of distal humerus
(cubitus varus deformity) admitted in orthopaedics department. This
study was performed from June, 2010 to October, 2012.
The inclusion criteria were; age of patient less than 15 years, varus
deformity due to malunited supracondylar fracture of humerus and

[Table/Fig-1]: The comparison between lateral closed wedge osteotomy and dome
osteotomy in terms of lateral condyle prominence.
Source online: https://o.quizlet.com/vAPuvm1WfQ1PIWul3ehTRw_m.png [Table/Fig-3]: Humerus-elbow-wrist angle measured using the Oppenheim method.
[Table/Fig-2]:: Preoperative X-ray and clinical photo. [Table/Fig-4]: Calculating the lateral condylar prominence index.

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 Partap Singh Verka et al., Management of Cubitus Varus Deformity in Children by Closed Dome Osteotomy www.jcdr.net

were drilled with help of Small Dynamic Compression Plate (SDCP) rotation by 100 to 200.
Mounted on the moore’s pin which was used as jig. A K-wire was 3. Unsatisfactory: When the changes surpass the above
passed distal to the osteotomy site, parallel to the articular surface. mentioned limits.
Another K-wire was passed parallel to this wire. Two K-wires were
also passed proximal to osteotomy site from lateral to medial side. RESULTS
The osteotomy holes were connected with help of 10 mm osteotome In our study, 68% of the cases were male, rest female. Almost 84%
to complete the break in the bone. Deformity was corrected under of the patients were in 5-10 years of age group while remaining
fluoroscopy by translating the distal fragment and derotating if 16% were of one to five years of age. Nearby, 56% of the cases
required. The K-wires were connected with mini external fixator involved left sided deformity while remaining 44% had right side
which was used as lateral tension band. An additional K-wire was involvement.
used if stability was in doubt. In addition, a ledge excision was done
Carrying angle on the normal side was more in females (average
prior to dome osteotomy in cases where anterior ledge was present
11.50) than in males (average 10.10). Carrying angle on the affected
which restricted the flexion movement at elbow.
side pre operatively and post operatively is shown in [Table/Fig-8].
Postoperative Protocol Degree of deformity, calculated by subtracting the carrying angle on
The limb was put to rest in an arm sling. Exercise was started once affected side from the carrying angle on normal side, was found to
the patient was pain free. Postoperative X-ray was taken [Table/ be 110 to 20° in 16% of the patients, 210 to 30° in 36% of patients,
Fig-6], carrying angle and LCPI were calculated. X-ray was repeated more than 30° in 48% of patients, while no patient had 00 to 10° of
after four weeks. K-wires and fixator were removed when there was deformity.
sufficient union. Follow up was done every four weeks with X-rays
till complete radiological union and complete expected results Lateral Condyle Prominent Index (LCPI)
were obtained. At final follow up carrying angle, LCPI and range of Pre operative LCPI ranged from -7.60% to +10.64%, average being
motion at elbow were checked [Table/Fig-7]. Parents and patients +1.18%. Post operative LCPI decreased, ranging from -9.09%
were asked about the cosmetic satisfaction with results. Result was to +3.00%, average being -2.75%. Change in LCPI ranged from
graded according to Mitchell and Adams Criteria [18] as under: +5.0% to -10.7%, with an average of -2.75%. Decrease in LCPI
resulted in better cosmetic appearance of elbow after surgery.
1. Excellent: Change in the carrying angle of less than 50,
restriction of movement in any plane less than 100.
Range of Motion at the Elbow
2. Good: Change in the carrying angle from 50 to 150 (i.e., not
Pre operatively eight patients (32%) had limitation of flexion while
beyond cubitus rectus), restriction of flexion, extension or
three pateints (12%) had limited extension. Rest 14 patients (56%)
had normal range of motion at the elbow. Post operative range of
motion is shown in [Table/Fig-9].

Complications
In this series no long term complications were observed. A few
complications occurred are as shown in [Table/Fig-10]. One case
of radial nerve neurapraxia occurred which recovered within three
months period.

Time of Osteotomy Union

Time of union ranged from four to eight weeks with an average of
6.3 weeks. Union occurred within four weeks in three cases (12%),
while 15 cases (60%) showed union time from four to six weeks.
Rest seven cases (28%) showed union within eight weeks.

Carrying Carrying
No of No of
angle (Pre Percentage angle (Post Percentage
Patients patients
operative) operative)

[Table/Fig-5]: Mid humeral axis over the AP radiograph of the affected side to propose 0° to -10° 5 20.0 0° to 5° 2 8.0
the site of osteotomy; [Table/Fig-6]: Postoperative X-ray.
-11° to -20° 13 52.0 6° to 10° 14 56.0

Less than
7 28.0 >10° 9 36.0
-20°

Total 25 100.0 Total 25 100.0

[Table/Fig-8]: Carrying angle on the affected side pre operatively and post operatively.

Postoperatively Range of
No of patients Percentage
Motion

Increased 11 44

0°-10°   3
Decreased 11°-20°   1 16
>20°    0

Full prior motion who regained

10 40
their full range

Total 25 100
[Table/Fig-9]: Post operative range of motion at elbow.
[Table/Fig-7]: Final follow-up X-ray and clinical photo.

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www.jcdr.net Partap Singh Verka et al., Management of Cubitus Varus Deformity in Children by Closed Dome Osteotomy

Evaluation of results rotation required for correction is less producing a much smaller
In our series we were able to achieve our aim of cosmetic correction varus moment, making the osteotomy mechanically more stable.
of varus which the patients and their parents reported subjectively Additionally, the muscles attached to distal fragment pull distal
also. According to Mitchell and Adams Criteria, result are shown in dome into claws of proximal fragment, reinforcing the stability [20].
[Table/Fig-11]. Ippolito E et al., reported 60% patients with unattractive post
operative scar after open dome osteotomy [21]. However, we
Complications No of patients %age performed percutaneous dome osteotomy. So none of the patient
Neurological injury 1 4
had unattractive scar except one in whom ledge excision was
done.
Vascular injury 0 0
Male to female ratio was 17:8 and the age group of our patients was
Postoperative oedema 4 16 4 to 10 years with an average of 7.7 years.
Infection 4 16 In the past, open approach either with triceps splitting or olecranon
Loss of correction 0 0 osteotomy was used to approach distal humerus. Reduction was
fixed using various mechanisms. Langenskiold A and Kivilaakso R
Implant failure 0 0
used a metal plate with screw for internal fixation [22]. Carlson CS Jr
Scar 0 0 and Rosman MA described use of lateral closing wedge osteotomy
Lateral bump 0 0 with staple fixation [23]. French PR advised a lateral closing wedge
osteotomy and internal fixation with two parallel screws and stainless
Total 9 36
steel wire [24].
[Table/Fig-10]: Complications.
In this study, only stab incisions were given to reach at the osteotomy
site under fluoroscopic guidance and reduction was fixed with mini
Results No of patients %age external fixator on lateral side. This stable fixation allowed us to
Excellent 22 88 commence physiotherapy in immediate post operative period.
Good 03 12 In our series 21 out of 25 patients (84%) reported no loss of range
Poor 00 00 of motion arc and four patients had loss of range of motion. In
contrast, all series of French osteotomy reported loss of range of
Total 25 100
motion arc in a significant number of patients. Bellemore M et al.,
[Table/Fig-11]: Results of our study according to Mitchell and Adams criteria.
reported loss of range of motion in 77% of patients after French
osteotomy [25]. Considering the results of our study, we are not
DISCUSSION aware of any previous study in which 44% patients reported gain in
Cubitus varus is one of the most common complication of range of motion arc and 40% patients reported no loss or gain in
supracondylar fracture of humerus in children treated with non range of motion arc. This can be attributed to early commencement
operative management without reduction and fixation, incidence of physiotherapy actively and passively which was possible due to
of which varies from 4% to 58%. Most surgeons consider the stable fixation. Other contributory factors were minimal soft tissue
deformity to result from inadequate reduction that leaves a residual handling and prevention of anterior angulation.
rotatory deformity that can collapse into medial tilt and result in a Upon analysing the results we found that 22 out of 25 patients
varus deformity. In India, such injuries are still commonly handled by carrying angle was within 5° of contralateral elbow which was
local bone setters rather than a certified orthopaedician. Most of the assigned as excellent outcome.
patients in this series were mainly the result of this practice. All the
cases were treated conservatively with no history of any associated In all series of dome osteotomy, LCPI improved indicating that dome
injuries. In cubitus varus, child often presents to improve the osteotomy is better than French osteotomy in term of prevention of
unsightly deformity, functionally the limb is not greatly disturbed. lateral condyle from being prominent.

In this study, all 25 cases presented for correction of deformity, In a study done by Tien YC et al., on 15 patients, the pre operative
eight patients had associated restricted movements at elbow joint carrying angle ranging from 19° to 31° varus showed improvement
due to anterior ledge. Parent’s concern was the major indication for to post operative carrying angle ranging from 7° to 15° valgus. Also,
surgery. the pre operative and post operative differences of LCPI ranged
from -67% to +6%, average being -30.1% [16].
The lateral closing wedge osteotomy is the most commonly used
procedure to correct the deformity. However, the appearance of the Our study showed the same improvement in LCPI which improved
joint post surgery is different from the unaffected side, although the in all but one patient gave good cosmetic outcome after a surgery
carrying angle was matched. Since this procedure does not allow which was done primarily for cosmetic purpose.
translation of the distal humerus, the residual cosmetic appearance In this study we did not find any loss of correction and one of our
might be due to a radial shift of distal fragment causing a protrusion patient suffered from complications like neuropraxia of radial nerve
of the lateral condyle. Wong HK et al., reported an incidence of 64% and four of our patients suffers from superficial pin tract infection
of this complication in a series of 22 patients [17]. and none of our patient suffers from complications like brachial
Apart from lateral condylar prominence, lateral closing wedge artery aneurysm, haematoma formation etc., which was seen in
osteotomy has another pitfall, the centre of rotation of distal humeral previous groups. All patients in our series were willing to get the
fragment is located at the medial cortex, making a large rotation surgery repeated under same circumstances.
arc necessary for correction of deformity. This results in further In our observation, we found that in younger age group rotation of
tightening of the already contracted medial structures and a large dome and correction of deformity was easier which was difficult in
varus movement acting on the osteotomy site. In this situation, the older age group due to tight soft tissue structures.
osteotomy is mechanically unstable and loss of correction would In our study, the results of deformity correction, in terms of elbow
occur easily if the fixation were inadequate [19]. range of motion, were comparable to lateral closed wedge
On the other hand, dome osteotomy uses the midline of the humerus osteotomy in various other studies. The outcome in terms of
as the centre of rotation, therefore the distal fragment does not shift lateral condyle prominence, cosmesis, maintenance of correction
laterally and is thus prevented from becoming prominent. Also, the and complications were superior in our study as compared

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 Partap Singh Verka et al., Management of Cubitus Varus Deformity in Children by Closed Dome Osteotomy www.jcdr.net

to lateral closing wedge osteotomy in other studies [26]. The [8] Noonan KJ, Jones JW. Recurrent supracondylar humerus fracture following prior
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traumatic cubitus varus in our series were comparable to those 76.
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PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of Orthopaedics, Government Medical College, Amritsar, Punjab, India.
2. Junior Resident, Department of Orthopaedics, Government Medical College, Amritsar, Punjab, India.
3. Junior Resident, Department of Orthopaedics, Government Medical College, Amritsar, Punjab, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr Partap Singh Verka,
Associate Professor and Incharge, Orthopaedics Unit No. 2; 1st Floor,
Guru Nanak Dev Hospital, Majitha Road, Amritsar-143001, Punjab, India. Date of Submission: Sep 22, 2016
E-mail: [email protected] Date of Peer Review: Oct 25, 2016
Date of Acceptance: Nov 19, 2016
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Mar 01, 2017

12 Journal of Clinical and Diagnostic Research. 2017 Mar, Vol-11(3): RC08-RC12