Ulnar nerve palsy after supracondylar humerus fracture

Six patients with cubitus varus deformity after a supracondylar fracture of the humerus had ulnar nerve palsy 7 (3-14) years following the fracture. All the patients showed anterior dislocation of the ulnar nerve during elbow flexion. In cubitus varus deformity, medial shifting of the triceps muscle occurs, which pushes the ulnar nerve anteriorly and frequently causes ulnar-nerve dislocation. Five of the 6 patients underwent surgery with subsequent improvement.     

Ulnar nerve palsy after supracondylar humerus fracture

Six patients with cubitus varus deformity after a supracondylar fracture of the humerus had ulnar nerve palsy 7 (3-14) years following the fracture. All the patients showed anterior dislocation of the ulnar nerve during elbow flexion. In cubitus varus deformity, medial shifting of the triceps muscle occurs, which pushes the ulnar nerve anteriorly and frequently causes ulnar-nerve dislocation. Five of the 6 patients under-went surgery with subsequent improvement.     

Conservative Treatment with Active Exercises in Osteoarthritis of the Hip

Six patients with cubitus varus deformity after a supracondylar fracture of the humerus had ulnar nerve palsy 7 (3–14) years following the fracture. All the patients showed anterior dislocation of the ulnar nerve during elbow flexion. In cubitus varus deformity, medial shifting of the triceps muscle occurs, which pushes the ulnar nerve anteriorly and frequently causes ulnar-nerve dislocation. Five of the 6 patients under-went surgery with subsequent improvement.     

A new osteotomy for cubitus varus

From 1974 to 1986, a step-cut technique of distal humerus valgus osteotomy using one cortical screw for fixation was used to correct cubitus varus deformity in 11 patients. The results were graded as excellent, eight patients, good, two, and poor, one. The poor result was secondary to persistent varus. The average humeral-elbow-wrist angle in the ten patients with valgus correction roentgenographically measured 9.3 degrees. The average amount of correction was 28.4 degrees. All patients retained their preoperative level of elbow motion. There were no radial or ulnar nerve injuries, nonunions, infections, or hypertrophic scars. The osteotomy requires careful preoperative planning and special attention to surgical detail. Large amounts of deformity may be corrected safely with a low complication rate.     

肱骨髁上骨折并发肘内翻畸形病理形态学分析

目的 :探讨肘内翻发生的病理形态学的改变特点。方法 :对 5 0例肘内翻进行X线片及术中所见病理形态学分析。结果 :大多数病例肱骨外髁膨大 ,内髁变小 ,滑车萎缩 ,尺骨鹰嘴窝变浅变形 ,肱骨远端尺偏、尺嵌及旋转 ,关节发育不均衡 ,尚有部分尺骨近端向肱骨尺神经沟方向滑脱。结论 :肘内翻是肱骨髁上骨折后由于肱骨远折端尺偏、尺嵌及内旋所引起 ,与骨骺损伤无关。内翻严重且日久者可造成肘关节的不稳定 ,关节面的不平衡从而出现肘外侧压痛等症状。宜早期发现 ,及早手术矫正。     

Cubitus varus associated with dislocation of both the medial portion of the triceps and the ulnar nerve.

Five patients with cubitus varus deformities from malunited childhood fractures had dislocation (snapping) of both the medial portion of the triceps and the ulnar nerve over the medial epicondyle. In addition to snapping, these patients had medial elbow pain or ulnar nerve symptoms. Cubitus varus shifts the line of pull of the triceps more medial, which can cause anteromedial displacement of the medial portion of the triceps during elbow flexion. The ulnar nerve is concomitantly pushed or pulled anteromedially by the triceps, and ulnar neuropathy may result from friction neuritis or from dynamic compression by the triceps against the epicondyle. Recognition of both the dislocating ulnar nerve and the snapping medial triceps is crucial in the successful treatment of this pathologic finding. In symptomatic individuals, we recommend either corrective valgus osteotomy of the distal humerus or partial excision or lateral transposition of the snapping medial triceps, or a combination of both. Alternatively, medial epicondylectomy can also eliminate the snapping. Transposition of the ulnar nerve can be performed for ulnar nerve symptoms and/or ulnar nerve instability. Using this approach, correction of the snapping and/or ulnar nerve symptoms was achieved in all cases.     

Tardy ulnar nerve palsy in cubitus varus deformity associated with ulnar nerve dislocation in adults

Seven patients with tardy ulnar nerve palsy from a posttraumatic cubitus varus deformity were reviewed retrospectively. The severity of symptoms was grade I in 3 patients and grade II in 4 patients according to McGowan's classification. The mean internal rotation angle was 30.7 degrees (range, 25 degrees -45 degrees ). The most prominent feature was dislocation of the nerve anterior to the medial epicondyle and entrapment of the nerve by the fibrous band of the flexor carpi ulnaris muscle. Of these 7 patients, 4 were treated by 3-dimensional osteotomy with ulnar nerve transposition, and 3 were treated by anterior transposition of the ulnar nerve. All patients improved clinically, and there was no significant difference between anterior transposition of the nerve in the group with osteotomy and the group without osteotomy. Ulnar nerve instability due to internal rotation deformity and distal entrapment was considered to be the main cause of neuropathy.     

Tardy ulnar nerve palsy after fracture non-union medial epicondyle of humerus – An unusual case

Tardy ulnar nerve palsy is a chronic clinical condition characterised by delayed onset ulnar neuropathy. Typically tardy ulnar nerve palsy occurs as a consequence of non-union of lateral condyle in child resulting in cubitus valgus deformity which ultimately is the cause of ulnar nerve palsy. However very few literature are available for tardy ulnar nerve palsy as a result of old fracture of medial epicondyle without cubitus varus or valgus deformity. We report a rare case of tardy ulnar nerve in an adult male with fracture non-union of medial epicondyle of humerus.     

Supracondylar corrective osteotomy in post-traumatic cubitus varus. 3 cases in 2 patients

Supracondylar fractures of the humerus in childhood frequently result in cubitus varus deformity. Pain, functional impairment and cosmetic problems can request surgical correction. This is a report on an adult and on a mature child with such deformities. The boy had sustained three injuries with following bilateral cubitus varus and lengthening of one lower leg. Planning, surgical technique and outcome of the osteotomies are described. We should recommend the resection of a full wedge with two oblique osteotomies and internal fixation with two plates on either side of the humerus.     

闭合复位克氏针内固定治疗GartlandⅢ型儿童肱骨髁上骨折

目的探讨闭合复位内外侧3针交叉固定治疗GartlandⅢ型儿童肱骨髁上骨折的疗效。方法对195例GartlandⅢ型儿童肱骨髁上骨折患者行闭合复位后,C臂机监视下先在肱骨髁外侧用2枚克氏针平行或交叉固定,再伸直肘关节到50°,保护尺神经下用1枚克氏针在内侧交叉固定,术后长臂石膏托固定于肘关节伸直70°制动3周。结果 195例均获随访,时间5~35个月。出现医源性尺神经损伤2例,肘内翻畸形需截骨矫形1例,肘部前侧局限性骨化4例。按Flynn标准评定疗效:优180例,良8例,一般6例,差1例,优良率为96.4%。结论闭合复位内外侧3针交叉固定治疗GartlandⅢ型儿童肱骨髁上骨折可有效减少医源性尺神经损伤,降低肘内翻畸形发生率,疗效满意。     

Supracondylar medial open wedge osteotomy with external fixation for cubitus varus deformity

BACKGROUND: Many surgical procedures are used for the correction of cubitus varus deformity in children. Even if the primary indication is cosmetic, but many poor results have been described. The technique of a supracondylar medial opening wedge osteotomy with external fixation is presented and preliminary results in four cases are reported. TECHNIQUE: An antero-medial approach is chosen with exposition and anterior transposition of the ulnar nerve. Under image intensifier control, insertion of four Schanz screws is performed from medial to lateral. In between, an incomplete medial osteotomy is performed obliquely (in the antero-posterior as well as in the medio-lateral plane), leaving a small part of the radial humeral cortex intact. The osteotomy is opened until varus and, if present, hyperextension deformation are corrected. Then, the fixator system is applied. RESULTS: All osteotomies healed primarily. Mean valgus correction of 21.75 degrees was achieved; in only one patient additional flexion modification of 17 degrees was necessary. At a follow-up of at least 2 years clinically three out of four presented symmetric elbow position, one slight residual varus deformity was noted in spite of 20 degrees of valgization due to important valgus position of the contralateral side. No lateral bulging of the corrected elbow was observed. CONCLUSION: The described technique is an alternative to other procedures, with special regard to the cosmetic outcome as well as to the control of correction for valgus and flexion.     

Posttraumatic progressive cubitus varus deformity managed by lateral column shortening: A novel surgical technique

The outward angulation of elbow with supinated forearm is cubitus varus deformity. This deformity is often seen as sequelae of malunited supracondylar fracture of humerus in paediatric age group of 5e8 years. The deformity is usually non-progressive, but in cases of physeal injury or congenital bony bar formation in the medial condyle of humerus, the deformity is progressive and can be grotesque in appearance. Various types of osteotomies are defined for standard non-progressive cubitus varus deformity, while multiple surgeries are required for progressive deformity until skeletal maturity. In this study we described a novel surgical approach and osteotomy of distal humerus in a 5 years old boy having grotesque progressive cubitus varus deformity, achieving good surgical outcome.     

Three-dimensional corrective osteotomy for cubitus varus in adults

In 23 adult patients, cubitus varus deformity was corrected by 3-dimensional osteotomy. During surgery, not only varus but internal rotation, flexion-extension deformity of the elbow, and lateral protrusion of the distal fragment were simultaneously addressed. The mean age of the patients was 26 years. Three showed tardy ulnar nerve palsy. The follow-up period after osteotomy averaged 1 year 10 months. The humeral-elbow-wrist angle improved from a mean 26 degrees of varus preoperatively to a mean of 3 degrees of valgus postoperatively. The mean internal rotation angle improved from 25 degrees to 5 degrees. As there was no recurrence of the deformity, this method of 3-dimensional corrective osteotomy for the treatment of cubitus varus in skeletally mature adults is recommended.     

The equal limbs lateral closing wedge osteotomy for correction of cubitus varus in children

Many methods have been described for correction of cubitus varus; the lateral closing-wedge osteotomy of French is the most popular. Although many authors reported successful correction, some authors since then have been critical of that osteotomy, alluding to problems with a lateral bulge or the scar. The aim of the present study is to evaluate a technique of correction of posttraumatic cubitus varus in children with an equal limbs laterally closing-wedge osteotomy of the distal humerus. From 2003 to 2006, twelve patients underwent supracondylar osteotomies for correction of cubitus varus in the Mansoura University Hospital. The average age was 8.7 years. The average follow-up was 20 months. The average preoperative carrying angle was 25 degrees varus, and this was corrected to an average of 5 degrees valgus. There was no noticeable prominence of the lateral condyle or an unsightly scar. This study shows that the equal limbs laterally closing-wedge osteotomy is simple, safe, and associated with an excellent cosmetic outcome and a low complication rate.     

Tardy posterolateral rotatory instability of the elbow due to cubitus varus

BACKGROUND: Cubitus varus has long been considered merely a cosmetic deformity. The purpose of this paper is to demonstrate a causal relationship between cubitus varus and instability of the elbow. METHODS: In twenty-four patients (twenty-five limbs) with a cubitus varus deformity following a pediatric distal humeral fracture or resulting from a congenital anomaly (three limbs of two patients), tardy posterolateral rotatory instability of the elbow developed approximately two to three decades after the deformity occurred. All patients presented with lateral elbow pain and recurrent instability. The average varus deformity was 15 degrees (range, 0 degrees to 35 degrees ). Surgery was performed in twenty-one patients (twenty-two limbs). Treatment consisted of reconstruction of the lateral collateral ligament and osteotomy in seven limbs, ligament reconstruction alone in ten, osteotomy alone in four, and total elbow arthroplasty in one. RESULTS: In three patients, the triceps muscle was dynamically stimulated intraoperatively to contract while resisting extension of the elbow. This produced posterolateral rotatory subluxation of the elbow, which was reversed by corrective osteotomy and lateral transposition of a portion of the medial head of the triceps that originally had been attached to the elongated, deformed medial aspect of the olecranon. At an average of three years (minimum, one year) after the operation, the result was good or excellent for nineteen of the twenty-two limbs that had undergone an operation; three limbs had persistent instability. CONCLUSIONS: With cubitus varus, the mechanical axis, the olecranon, and the triceps line of pull are all displaced medially. The repetitive external rotation torque on the ulna permitted by these deformities can stretch the lateral collateral ligament complex and lead to posterolateral rotatory instability. Thus, cubitus varus deformity secondary to supracondylar malunion or congenital deformity of the distal part of the humerus may not always be a benign condition and may have important long-term clinical implications. Operative correction can relieve symptoms of instability. The indications for preventive corrective osteotomy remain to be determined.     

Remodeling after lateral closing-wedge osteotomy in children with cubitus varus

The purpose of this study was to evaluate the effectiveness of supracondylar lateral closing-wedge osteotomy of the humerus in children and the postoperative remodeling of the lateral condylar prominence. Lateral closing-wedge osteotomy for cubitus varus deformity was performed in 52 children. In all cases, medial translation for decreasing lateral condylar prominence or transposition of the ulnar nerve was not performed. Mean patient age was 8.8 years. Mean follow-up was 42 months. Clinical and radiological results were analyzed at last follow-up. Mean range of motion of the elbow in flexion and extension improved significantly (P<.05). Mean humeroulnar angle and mean shaft-condylar angle were significantly corrected (P<.05), and the angles between the affected and contralateral sides were not significantly different at last follow-up. Mean lateral condylar prominence index significantly decreased from 38.8% to 3.4%, and mean lateral condylar prominence amount decreased from -31.6% to -65.0% (P<.05 and P<.05, respectively). The amount of lateral condylar prominence remodeling was statistically correlated with the severity of preoperative cubitus varus, length of follow-up, and age at operation (P<.05 for all). The mean change in lateral condylar prominence amount in patients younger than 11 years (36.6%) was significantly greater than the mean change in lateral condylar prominence amount in patients aged 12 years or older (20.4%) (P=.001). Supracondylar lateral closing wedge osteotomy of the humerus is a simple and effective operation for correction of cubitus varus in children younger than 11 years with a considerable amount of lateral condylar prominence remodeling.     

Tardy ulnar nerve palsy caused by cubitus varus deformity

Clinical features and X-rays of thirty-four cases with cubitus varus deformity were analysed in order to explain the occurrence of tardy ulnar nerve palsy caused by cubitus varus deformity. Cubitus varus cases with tardy ulnar nerve palsy, compared to cases without it, were older at the first visit to the clinic for cubitus varus deformity. There were no other differences between the two groups in clinical features. Computed tomography showed that the olecranon moved to the ulnar side against the olecranon fossa. Operative findings showed that the medial head of triceps brachii shifted medially and covered the ulnar nerve. Both from computed tomography and operative findings we conjectured the possibility that tardy ulnar nerve palsy was caused because the ulnar nerve was compressed by the forward medial movement of the medial head of the triceps brachii caused by cubitus varus deformity.     

Dome osteotomy for posttraumatic cubitus varus: a surgical technique to avoid lateral condylar prominence

The indication for surgery in most children with posttraumatic cubitus varus is the presence of an unsightly deformity. The function of the limb is generally not impaired. Lateral closing-wedge supracondylar osteotomy, although a widely used corrective procedure, tends to produce lateral condylar prominence, thus jeopardizing the cosmetic outcome. The authors used the dome supracondylar osteotomy, as described by Tien et al, as the corrective procedure for cubitus varus in 12 consecutive children. The average follow-up was 2.3 (range 1-4) years. The objective evaluation was done by one of the authors by measuring the pre- and postoperative lateral condylar prominence index, carrying angle, and the range of movement at the elbow. The patients and parents were also asked to self-assess the cosmetic outcome. There were seven excellent and five good results. None of the children showed a prominent lateral humeral condyle. Hypertrophic scar formation and ulnar neurapraxia were seen in one patient each. These results were comparable to the published results of lateral closing-wedge osteotomy in terms of correction of carrying angle and preservation of elbow motion and were superior to those of the lateral closing-wedge osteotomy in terms of the prominence of lateral humeral condyle, acceptability of the scar, and cosmesis. The authors offer independent verification of the observation that the technique of dome osteotomy as described by Tien et al for the correction of the posttraumatic cubitus varus is a simple, safe, and technically sound procedure that prevents the lateral condyle from becoming prominent and yields an excellent cosmetic outcome.     

Correction of cubitus varus by French or dome osteotomy: a comparative study

BACKGROUND: The purpose of this study was to compare the outcomes of two different techniques of supracondylar osteotomy, French osteotomy and dome osteotomy, for the correction of posttraumatic cubitus varus. METHODS: A comparative randomized study was undertaken of 25 patients (average age 10 years) with an established posttraumatic cubitus varus deformity (mean time from injury to corrective osteotomy, 1.7 years). Patients were followed-up with for 1 year, and carrying angle, Baumann's angle, and internal rotation deformity were measured. Postoperative complications were assessed. RESULTS: A significant (p < 0.01) correction of carrying angle and Baumann's angle was achieved with both techniques, with no statistically significant differences between them. Although internal rotation deformity was corrected by both techniques, the correction was significantly greater with the dome osteotomy (p < 0.01). However, the persistence of internal rotation did not seem to affect the final outcome. There was a higher incidence of postoperative complications in the dome osteotomy group, including infection (1), inadequate correction (1), nerve palsy (1), loss of motion (5), and circulatory compromise (1). CONCLUSION: The dome osteotomy is technically more difficult than the French osteotomy and has a higher incidence of complications. We suggest that the French osteotomy be used for the correction of cubitus varus after supracondylar fractures of the elbow in children.     

Failure of active extension after traumatic cubitus varus. A case report

In children cubitus varus is common after malunion of a supracondylar fracture of the humerus. Later problems such as tardy ulnar nerve palsy, snapping of the lateral triceps tendon or ulnar nerve and posterolateral rotatory instability are well documented. We present a case of anteromedial dislocation of the entire triceps tendon with loss of extensor power and describe the method of treatment.