Deformity correction of Elbow (Cubitus varus / Valgus)

The elbow joint plays a crucial role in the function of the upper limb, allowing for a wide range of motion including flexion, extension, pronation, and supination. Any deformity affecting the elbow can significantly impair arm function and aesthetics. Among the common deformities of the elbow are Cubitus Varus and Cubitus Valgus, which refer to abnormal angulations of the forearm relative to the upper arm when the elbow is extended.

Understanding Elbow Deformities: Cubitus Varus and Cubitus Valgus

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Cubitus Varus

Cubitus varus, often called the “gunstock deformity,” is characterized by an inward angulation of the forearm relative to the humerus when the arm is extended and supinated. In this condition, the forearm deviates towards the midline of the body, resulting in a varus (medial) angulation at the elbow.

This deformity is most commonly a sequela of malunited supracondylar fractures of the distal humerus in children. It can also result from growth disturbances or improper healing after trauma.

Cubitus Valgus

Cubitus valgus is the opposite deformity, where the forearm deviates away from the midline, creating a valgus (lateral) angulation at the elbow. This condition is less common than cubitus varus and may arise due to lateral condyle fractures, growth plate injuries, or congenital causes.

Cubitus valgus is clinically significant because it can be associated with tardy ulnar nerve palsy due to stretching of the ulnar nerve over the medial epicondyle.

Causes and Pathophysiology

Causes of Cubitus Varus

Malunited supracondylar fractures: The most frequent cause, especially in pediatric patients.
Growth disturbances: Damage to the growth plate of the distal humerus can lead to asymmetric growth and deformity.
Post-traumatic malalignment: Improper reduction or fixation of fractures.
Congenital deformities: Rarely, congenital anomalies can cause varus deformity.

Causes of Cubitus Valgus

Lateral condyle fractures: Malunion or nonunion can cause valgus angulation.
Growth plate injuries: Premature closure of the medial growth plate.
Congenital causes: Such as multiple hereditary exostoses.
Post-infectious or post-inflammatory conditions: Leading to growth disturbances.

Clinical Presentation

Symptoms

Visible deformity of the elbow with abnormal angulation.
Limited range of motion, especially in severe cases.
Cosmetic concerns, particularly in children and adolescents.
In cubitus valgus, symptoms of ulnar nerve irritation such as numbness, tingling, or weakness in the hand.
Occasional pain or discomfort during activities.

Physical Examination

Inspection reveals the characteristic angulation of the forearm relative to the upper arm.
Measurement of the carrying angle: Normally, the carrying angle is about 5-15 degrees valgus in adults.
Assessment of range of motion: Flexion, extension, pronation, and supination.
Neurological examination to assess ulnar nerve function.
Comparison with the contralateral elbow.

Diagnosis

Radiological Evaluation

X-rays: Anteroposterior (AP) and lateral views of the elbow are essential.
- In cubitus varus, the humero-ulnar angle is decreased or negative.
- In cubitus valgus, the angle is increased beyond normal limits.
Measurement of carrying angle: The angle between the long axis of the humerus and the forearm.
CT scan or 3D imaging: May be used in complex deformities for preoperative planning.

Other Investigations

Electromyography (EMG) and nerve conduction studies if ulnar nerve involvement is suspected.
Clinical photographs for documentation.

Treatment Options

The management of cubitus varus and valgus deformities depends on the severity of the deformity, symptoms, patient age, and functional impairment.

Non-Surgical Management

Mild deformities without functional limitation or cosmetic concern may be observed.
Physical therapy to maintain range of motion.
Regular follow-up to monitor progression.

Surgical Management

Surgery is indicated in cases with significant deformity, functional impairment, or neurological symptoms.

Goals of Surgery

Correct the angular deformity to restore normal carrying angle.
Improve cosmetic appearance.
Prevent or relieve ulnar nerve symptoms.
Restore elbow function.

Surgical Techniques for Deformity Correction

Osteotomy

Osteotomy is the most common surgical procedure for correcting cubitus varus or valgus. It involves cutting and realigning the distal humerus to correct the angulation.

Types of Osteotomy

Lateral Closing Wedge Osteotomy
- Most commonly used for cubitus varus.
- A wedge of bone is removed from the lateral side of the distal humerus.
- The bone is then realigned and fixed with plates, screws, or pins.
- Advantages: Simple, reliable correction.
- Disadvantages: Potential limb shortening.
Medial Opening Wedge Osteotomy
- Used less frequently.
- A wedge is opened on the medial side and bone grafting is required.
- Useful in cubitus valgus correction.
Dome Osteotomy
- Allows multiplanar correction.
- Circular cut enables rotation and angulation correction.
- Technically demanding but versatile.
Step-Cut Osteotomy
- Provides stable fixation.
- Allows precise correction of deformity.

Fixation Methods

Kirschner wires (K-wires)
Plates and screws (locking plates preferred for stability)
External fixators in complex cases

Ulnar Nerve Management

In cubitus valgus with ulnar nerve symptoms, anterior transposition of the ulnar nerve may be performed.
Careful handling of the nerve during surgery is essential to prevent iatrogenic injury.

Postoperative Care and Rehabilitation

Immobilization in a cast or splint for 3-6 weeks depending on fixation stability.
Early gentle range of motion exercises to prevent stiffness.
Gradual strengthening exercises.
Regular follow-up with X-rays to monitor healing.
Monitoring for complications such as infection, nonunion, nerve injury, or recurrence of deformity.

Conclusion

Deformities of the elbow such as cubitus varus and cubitus valgus can significantly affect arm function and appearance. While mild cases may be managed conservatively, significant deformities often require surgical correction through osteotomy and realignment. Advances in surgical techniques and fixation methods have improved outcomes, allowing patients to regain normal elbow function and appearance. Early diagnosis, appropriate treatment, and dedicated rehabilitation are key to successful deformity correction.

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