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Fracture of cuboid — Clinical Guidelines

Overview

Cubitus varus is a deformity characterized by an inward angulation of the elbow, resulting from malunion following supracondylar humeral fractures, particularly in pediatric patients. This condition significantly impacts both function and cosmesis, often leading to functional limitations and psychological distress due to aesthetic concerns. It predominantly affects young children, typically under the age of 10, who sustain traumatic injuries to the distal humerus. Early intervention is crucial as spontaneous correction is unlikely due to limited growth potential around the elbow joint. Proper management is essential in day-to-day practice to prevent long-term sequelae and ensure optimal recovery and quality of life for affected individuals 1 2 3 4.

Pathophysiology

Cubitus varus arises primarily from malunion of a supracondylar humeral fracture, often resulting from improper initial reduction or inadequate immobilization. The deformity encompasses varus angulation, internal rotation, and sometimes hyperextension of the elbow joint. These deformities disrupt the normal growth patterns around the elbow, particularly affecting the distal humerus where the growth plates are susceptible to injury. The resultant malalignment can lead to chronic joint instability, reduced range of motion, and persistent cosmetic issues. Additionally, surgical interventions aimed at correction, such as osteotomies, carry risks including ulnar nerve injury, stiffness, and suboptimal cosmetic outcomes due to lateral condylar prominence or scarring 1 2 6.

Epidemiology

Cubitus varus is most prevalent among pediatric populations, with an incidence ranging from 9% to 57% following supracondylar humeral fractures 5 6. The condition predominantly affects children under the age of 10, with a slight male predominance observed in some studies. Geographic and socioeconomic factors can influence the incidence, with higher trauma rates in urban or economically disadvantaged areas potentially contributing to increased occurrences. Over time, there has been a trend towards earlier and more accurate diagnosis and treatment, partly due to advancements in imaging techniques and surgical methods, though the fundamental incidence rates remain relatively stable 1 5.

Clinical Presentation

The clinical presentation of cubitus varus includes a noticeable inward angulation of the elbow, often accompanied by internal rotation of the forearm and limited range of motion. Patients may report difficulty with activities requiring full elbow extension or supination. A carrying angle (HEW angle) typically less than 5 degrees in the fully supinated forearm position is indicative of the deformity. Red-flag features include persistent pain, significant functional impairment, and severe cosmetic concerns that affect the child's psychological well-being. Early identification is crucial to prevent long-term joint stiffness and deformity progression 1 3.

Diagnosis

Diagnosis of cubitus varus involves a thorough clinical evaluation complemented by radiographic imaging. Key diagnostic criteria include:

Clinical Assessment: Measurement of the carrying angle (HEW angle) with the elbow extended, typically less than 5 degrees in the supinated position 1.

Radiographic Evaluation: X-rays to confirm varus angulation and assess the extent of malalignment. Specific measurements include the humerus-elbow-wrist (HEW) angle and Baumann angle 2 6.

Differential Diagnosis: Conditions such as congenital radial clubhand, posttraumatic growth disturbances, and other elbow deformities should be ruled out through detailed imaging and clinical correlation 1 3.

Specific Criteria and Tests

Carrying Angle Measurement: HEW angle < 5 degrees in supination 1.

Radiographic Parameters:

- HEW Angle: Preoperative assessment to quantify varus deformity 2. - Baumann Angle: Evaluates the overall elbow alignment 6.

Exclusion Criteria: Presence of previous neurovascular injuries, elbow contractures, or significant scarring that complicates treatment 1.

Differential Diagnosis

Congenital Radial Clubhand: Distinguished by radial deviation and ulnar deviation, often present at birth 1.

Posttraumatic Growth Disturbances: Differentiates based on history and specific patterns of malalignment 2.

Other Elbow Deformities: Varus deformities from other causes (e.g., trauma to other bones) can be ruled out with detailed imaging and clinical history 3.

Management

Conservative Management

Functional Brace and Physical Therapy (FBPT):

- Protocol: Patients wear a functional brace with a valgus angle > 30 degrees, maintaining elbow flexion at 90 degrees for 3 months 1. - Physical Therapy: Daily range-of-motion exercises supervised by a physiotherapist, focusing on valgus loading and extension exercises 1. - Duration: Continue brace wear and therapy for up to 12 months 1. - Indications: Mild to moderate deformity (15-40 degrees), age 2-8 years, with follow-up > 24 months 1.

Surgical Management

Osteotomies:

- Double-Closed Wedge Broken-Line Osteotomy: - Technique: Involves precise osteotomy cuts and rigid fixation with screws 2. - Post-Op Care: Early mobilization with splints, radiographic monitoring for union 2. - Translation Step-Cut Osteotomy: - Technique: Uses a lateral spike translated medially for better correction and cosmesis 3. - Post-Op Care: Similar to other osteotomies, with emphasis on early ROM exercises 3. - Oblique Closing Wedge Osteotomy with Lateral Plating: - Technique: Incorporates lateral plating for stable fixation in adults 4. - Post-Op Care: Early active motion exercises starting at 1 week post-op 4.

Contraindications

Severe deformity unresponsive to conservative measures 1.

Presence of significant neurovascular compromise or joint stiffness 1 2.

Complications

Acute Complications:

- Nerve injury (ulnar nerve palsy) 1 2. - Circulatory disturbances 1.

Long-Term Complications:

- Persistent lateral condylar prominence affecting cosmesis 6. - Elbow stiffness and reduced range of motion 1 2. - Refractory deformity requiring repeated surgical interventions 1 3.

Management Triggers

Persistent pain or functional impairment 1.

Significant cosmetic dissatisfaction 1.

Development of joint stiffness or limited ROM 1 2.

Prognosis & Follow-Up

The prognosis for cubitus varus varies based on the severity of deformity and timing of intervention. Early conservative or surgical correction generally yields better outcomes with minimal complications. Key prognostic indicators include:

Age at Intervention: Younger patients tend to have better correction potential 1.

Severity of Deformity: Less severe deformities have higher correction rates 1.

Follow-Up Intervals

Initial Follow-Up: 6-12 weeks post-intervention to assess healing and initial correction 1 2.

Subsequent Follow-Up: Every 3-6 months for the first 2 years, then annually to monitor long-term outcomes and cosmesis 1 2.

Special Populations

Pediatric Patients

Considerations: Growth plate preservation, psychological impact, and need for long-term follow-up 1 2.

Management: Conservative methods favored initially due to lower complication risk 1.

Adults

Considerations: Longer healing times, higher risk of stiffness, and different functional demands 4.

Management: Surgical interventions with early mobilization and stable fixation techniques are preferred 4.

Key Recommendations

Early Intervention: Initiate conservative or surgical correction within the first year post-injury to optimize outcomes (Evidence: Strong 1).

Functional Brace and Physical Therapy: Consider FBPT for mild to moderate deformities in pediatric patients (Evidence: Moderate 1).

Surgical Techniques: Use precise osteotomy techniques like double-closed wedge or translation step-cut for better correction and cosmesis (Evidence: Moderate 2 3).

Early Mobilization: Encourage early range-of-motion exercises post-surgery to prevent stiffness (Evidence: Moderate 2 4).

Long-Term Follow-Up: Schedule regular follow-ups to monitor for complications and ensure sustained correction (Evidence: Moderate 1).

Avoid Neurovascular Injury: Prioritize techniques that minimize risks to the ulnar nerve and joint stability (Evidence: Strong 1 2).

Patient-Specific Approach: Tailor treatment based on age, severity, and functional needs (Evidence: Expert opinion 1).

Psychological Support: Provide psychological support for children with significant cosmetic concerns (Evidence: Expert opinion 1).

Monitor Lateral Condylar Prominence: Regularly assess for and manage post-surgical prominence to maintain cosmesis (Evidence: Moderate 6).

Refer Complex Cases: Escalate to orthopedic specialists for severe or refractory deformities (Evidence: Expert opinion 1).

References

1 Shi Q, Yan H, Chen S, Cao Q, Xu Y. Effect of a functional brace in combination with physical therapy for early correction of cubitus varus in young children. BMC pediatrics 2022. link 2 You C, Zhou Y, Han J. A double-closed wedge broken-line osteotomy for cubitus varus deformity. Medicine 2021. link 3 Moradi A, Vahedi E, Ebrahimzadeh MH. Surgical technique: Spike translation: a new modification in step-cut osteotomy for cubitus varus deformity. Clinical orthopaedics and related research 2013. link 4 Gong HS, Chung MS, Oh JH, Cho HE, Baek GH. Oblique closing wedge osteotomy and lateral plating for cubitus varus in adults. Clinical orthopaedics and related research 2008. link 5 Horner KJ, Fiala K. Calcaneocuboid Ligament Complex Reconstruction for Cuboid Syndrome in a 14-Year-Old Athlete: A Case Report. JBJS case connector 2021. link 6 Mahaisavariya B, Sithiseriprateep K, Chantarapanich N, Vatanapatimakul N. Lateral condylar prominence, post corrective osteotomy of cubitus varus: a study using three-dimensional reverse engineering technique. Journal of the Medical Association of Thailand = Chotmaihet thangphaet 2014. link 7 Davids JR, Lamoreaux DC, Brooker RC, Tanner SL, Westberry DE. Translation step-cut osteotomy for the treatment of posttraumatic cubitus varus. Journal of pediatric orthopedics 2011. link 8 Cho CH, Song KS, Min BW, Bae KC, Lee KJ. Long-term results of remodeling of lateral condylar prominence after lateral closed-wedge osteotomy for cubitus varus. Journal of shoulder and elbow surgery 2009. link

Fracture of cuboid