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Supracondylar fracture of the humerus: malrotation versus cubitus varus deformity
416
Injury (1993) 24, (6), 416-418
Prinfed in Greuf Britain
Supracondylar fracture of the humerus: malrotation versuscubitus varus deformity B. Mahaisavariya and W. Laupattarakasem Srinagarind
Hospital, Khon Kaen University,
Khon Kaen, Thailand
A sfudy correkxfing fhe degree of medial rotational kformify of the distal humerus and the degree of cubik varus deformify secondary to supracondylar frachtre was performed in 23 pafienfs who underwent corrective supracondylar osfeofomy. The mean age of the pafienfs at fhe time of operation was 10.9 years (range 5-14 years). The fime inferval from injury to operation averaged 3.2 years (range 1-6 years). A medial rofafional deformity occurred in 20 CLWS.The degree of medial rotational deformity (MRD) averaged 16.2” (‘rangeO-34”). Mean currying angks (CA) of the deformed and normal sides were - 19.6” and 6.5’, respecfively. Mean hwnero-elbow-wrist (HEW) angles, measured from radiographs, of the deformed and normal sides, were - 18.8” and 7.7”, respecfively.Therewas no correlafion befween the degree of MRD and the degree of varus deformity, using as a comparison either fhe CA or the HEW angle of the deformed elbow or their differencesfrom fhe twrmul side.
Introduction Cubitus varus deformity is a common complication of supracondylar fracture of the humerus in children. The deformity usually comprises varus, hyperextension and medial rotation elements in the distal humerus (Yamamoto et al., 1985). Although the varus component is now accepted as resulting from medial tilt of the distal fragment (Smith, 1960; Langenskiold and Kivilaakso, 19677, it is believed to occur secondarily to medial displacement or to medial rotation of the distal fragment (W&in, 1990). Although medial rotational deformity is often associated with varus deformity, a study correlating the degree of medial rotation and the degree of varus deformity has never been reported.
excluded were those in which the deformity was secondary to condylar fracture or epiphyseal injuries of the distal humerus, and cases in which the relationship of the previous fracture alignment could not be identified because of extensive remodelling. The varus deformity was determined both by clinical measurement of the carrying angle and by measurement of the humero-elbow-wrist angles from radiographs (Oppenheim et al., 1984). The carrying angles (CA) of both elbows were measured clinically with the elbows in extension and supination. The humero-elbow-wrist (HEW) angles were measured from the anteroposterior scanogram of both upper limbs. The medial rotational deformity of the distal humerus from previous malrotation alignment of supracondylar fractures could be determined from the cut surface at the osteotomy site as described previously (Laupattarakasem et al., 1989). The degree of medial rotational deformity was determined by the degree to which the new posterior border of the distal part deviated from the old posterior border (Figure I). This study was performed to
Materials and methods Between April 1990 and June 1992,69 patients with cubitus varus underwent supracondylar corrective osteotomy using the technique that we have reported previously at Srinagarind Hospital (Laupattarakasem et al., 1989). Of these, we are able to study 23 cases in which the deformity was secondary to supracondylar fracture. These patients underwent corrective osteotomy a few years after injury, so that the relationship between the previous fracture fragments could be identified from the osteotomy surface. Cases 0 1993 Butterworth-Heinemann 0020-1383/93/06041+03
Ltd
Figure I. The cut surface at the supracondylar osteotomy from a bone specimen shows the medial rotational deformity. The degree of medial rotational deformity is determined by the degree to which the new posterior border (outer arrow) deviates from the original posterior border (inner arrow).
Mahaisavariya and Laupattarakasem:
Supracondylar fracture of the humerus
417
Table I. Details of the clinical data of the study Carrying angle (3 Age
Sex
Side
Duration (Years)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
5 13 9 5 10 12 14 13 14 10 14 13 14 12 12 9 7 10 12 13 9 13 8
F F M M F F F F F M M M M M F F M M F F F F M
R R R L R L R L L L L L R R L L R L L L L L R
Mean
10.9
Case
D
N
1 4 1 1 6 3 6 1.5 5 3 1.5 2 4 5 6 3 1.5 3 6 5 2 4 1
-25 -20 -25 -20 -15 -15 -20 -25 -15 -10 -20 -25 -20 -15 -15 -30 -20 -25 -20 -20 -15 -15 -20
5 7 5 5 8 10 8 5 10 10 10 5 5
3.2
- 19.6
D = deformed sided, N = normal side, H-E-W = humero-elbow-wrist,
identify any significant correlation between the degree of MRD and the degree of varus deformity, as determined either by the CA or by the HEW angle of the deformed side.
Results The clinical data are shown in TableI. There were 10 males and 13 females. The left elbow was affected in 14 cases and right elbow in nine. Patient age at the time of operation averaged 10.9 years (range 5-14 years). The time from injury to operation ranged from 1 to 6 years (average 3.2 years). Means of the carrying angle of the deformed and the normal side were - 19.6” and 6.5” respectively. Means of the HEW angles of the deformed and the normal sides were - 18.8” and 7.7” respectively. There was no significant correlation between the degree of MRD and the degree of varus deformity measured by using the CA or the HEW angles of the deformed side (correlation coefficients r= - 0.08 and - 0.02). There was also no significant correlation between the degree of MRD and the difference between the CA or the HEW angles of the deformed side and the CA or HEW angles of the normal side, respectively (r = 0.0217 and 0.044, respectively).
H-E-Wangles
(“)
D
N
(N-D)
MRD
z 5 5 5 5 5 7 7 5
-25 -18 -22 -18 -12 -13 -26 -26 -16 -12 -22 -24 -15 -6 -16 -27 -20 -22 -20 -22 -18 -15 -18
10 8 7 7 10 10 11 7 8 8 8 7 10 5 8 6 8 7 5 5 7 8 7
(35) (26) (29) (25) (22) (23) (37) (33) (24) (20) (30) (31) (25) (11) (24) (33) (28) (29) (25)
10 22 15 20 27 0 15 18 25 0 11 15 8 22 34 24 9 32 0 13 16 30 8
6.5
- 18.8
(N-D)
7.7
(27) (25) (23) (25) (26.5)
16.2
MRD = medial rotational deformity.
correct the varus deformity, even in children, without waiting for closure of the epiphyseal plate of the distal humerus. This has made it possible to conduct this study, because the corrective osteotomy is performed soon after the injury. As our method of corrective osteotomy is performed in the supracondylar region, studying the rotational deformity from the cut surface at the osteotomy site is most helpful in documenting the actual rotational deformity. The old posterior border can be differentiated from that of the newly formed posterior border intraoperatively when the deformity is operated on soon after the injury and before remodelling masks the native bone. The findings can be used to trace the fracture alignment that existed previously in this area. Although medial rotational deformity is usually associated with cubitus varus deformity, the results show no correlation between the degree of rotational deformity and that of the varus deformity. It is therefore probable that the severity of malrotation of the supracondylar fracture does not contribute to the severity of the varus deformity of the elbow.
Acknowledgements Discussion Cubitus varus deformity is a common elbow deformity among children in Thailand. The deformity usually results from poor treatment of the supracondylar fracture by bone-setters. The fracture is not usually reduced and is held with the elbow in extension using the multiple-strip bamboo splint. Most of our patients seek treatment to correct the cubitus varus a few years later, after they have realized that the deformity does not regress with time. It is our policy to
We thank Mr David Narot for editorial assistance.
References Langenskiold A. and Kivilaakso R. (1967) Varus and valgus deformity of the elbow following supracondylar fracture of the humerus. Acfa Orfhop. Scand. 38,313.
418
Injury: International Journal of the Care of the Injured (1993) Vol. 24/No.
Laupattarakasem W., Mahaisavariya B., Kowsuwon W. et al. (1989) Pentalateral osteotomy for cubitus varus: clinical experiences of a new technique. ]. Bane]oint Surg. 71B,667. Oppenheim W. L., Clader T. J. Smith C. et al. (1984) Supracondylar humeral osteotomy for traumatic childhood cubitus varus deformity. Clin. orthop. 188,34. Smith L. (1960) Deformity following supracondylar fractures of the humerus. J. Bone Joint Surg. 42A, 235. Wilkin K. E. (1990) Residuals of elbow trauma in children. Orthop. Clin. North Am. 21,291.
6
Yamamoto I., Ishii S., Usui M. et al. (1985) Cubitus varus deformity following supracondylar fracture of the humerus: a method for measuring rotational deformity. Clin. Or&p. 201,179. Paper accepted
20 November
1992.
Requests for reprints should be addressed to: B. Mahaisavariya MD, Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand.
Injury (1993) 24, (6), 416-418
Prinfed in Greuf Britain
Supracondylar fracture of the humerus: malrotation versuscubitus varus deformity B. Mahaisavariya and W. Laupattarakasem Srinagarind
Hospital, Khon Kaen University,
Khon Kaen, Thailand
A sfudy correkxfing fhe degree of medial rotational kformify of the distal humerus and the degree of cubik varus deformify secondary to supracondylar frachtre was performed in 23 pafienfs who underwent corrective supracondylar osfeofomy. The mean age of the pafienfs at fhe time of operation was 10.9 years (range 5-14 years). The fime inferval from injury to operation averaged 3.2 years (range 1-6 years). A medial rofafional deformity occurred in 20 CLWS.The degree of medial rotational deformity (MRD) averaged 16.2” (‘rangeO-34”). Mean currying angks (CA) of the deformed and normal sides were - 19.6” and 6.5’, respecfively. Mean hwnero-elbow-wrist (HEW) angles, measured from radiographs, of the deformed and normal sides, were - 18.8” and 7.7”, respecfively.Therewas no correlafion befween the degree of MRD and the degree of varus deformity, using as a comparison either fhe CA or the HEW angle of the deformed elbow or their differencesfrom fhe twrmul side.
Introduction Cubitus varus deformity is a common complication of supracondylar fracture of the humerus in children. The deformity usually comprises varus, hyperextension and medial rotation elements in the distal humerus (Yamamoto et al., 1985). Although the varus component is now accepted as resulting from medial tilt of the distal fragment (Smith, 1960; Langenskiold and Kivilaakso, 19677, it is believed to occur secondarily to medial displacement or to medial rotation of the distal fragment (W&in, 1990). Although medial rotational deformity is often associated with varus deformity, a study correlating the degree of medial rotation and the degree of varus deformity has never been reported.
excluded were those in which the deformity was secondary to condylar fracture or epiphyseal injuries of the distal humerus, and cases in which the relationship of the previous fracture alignment could not be identified because of extensive remodelling. The varus deformity was determined both by clinical measurement of the carrying angle and by measurement of the humero-elbow-wrist angles from radiographs (Oppenheim et al., 1984). The carrying angles (CA) of both elbows were measured clinically with the elbows in extension and supination. The humero-elbow-wrist (HEW) angles were measured from the anteroposterior scanogram of both upper limbs. The medial rotational deformity of the distal humerus from previous malrotation alignment of supracondylar fractures could be determined from the cut surface at the osteotomy site as described previously (Laupattarakasem et al., 1989). The degree of medial rotational deformity was determined by the degree to which the new posterior border of the distal part deviated from the old posterior border (Figure I). This study was performed to
Materials and methods Between April 1990 and June 1992,69 patients with cubitus varus underwent supracondylar corrective osteotomy using the technique that we have reported previously at Srinagarind Hospital (Laupattarakasem et al., 1989). Of these, we are able to study 23 cases in which the deformity was secondary to supracondylar fracture. These patients underwent corrective osteotomy a few years after injury, so that the relationship between the previous fracture fragments could be identified from the osteotomy surface. Cases 0 1993 Butterworth-Heinemann 0020-1383/93/06041+03
Ltd
Figure I. The cut surface at the supracondylar osteotomy from a bone specimen shows the medial rotational deformity. The degree of medial rotational deformity is determined by the degree to which the new posterior border (outer arrow) deviates from the original posterior border (inner arrow).
Mahaisavariya and Laupattarakasem:
Supracondylar fracture of the humerus
417
Table I. Details of the clinical data of the study Carrying angle (3 Age
Sex
Side
Duration (Years)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
5 13 9 5 10 12 14 13 14 10 14 13 14 12 12 9 7 10 12 13 9 13 8
F F M M F F F F F M M M M M F F M M F F F F M
R R R L R L R L L L L L R R L L R L L L L L R
Mean
10.9
Case
D
N
1 4 1 1 6 3 6 1.5 5 3 1.5 2 4 5 6 3 1.5 3 6 5 2 4 1
-25 -20 -25 -20 -15 -15 -20 -25 -15 -10 -20 -25 -20 -15 -15 -30 -20 -25 -20 -20 -15 -15 -20
5 7 5 5 8 10 8 5 10 10 10 5 5
3.2
- 19.6
D = deformed sided, N = normal side, H-E-W = humero-elbow-wrist,
identify any significant correlation between the degree of MRD and the degree of varus deformity, as determined either by the CA or by the HEW angle of the deformed side.
Results The clinical data are shown in TableI. There were 10 males and 13 females. The left elbow was affected in 14 cases and right elbow in nine. Patient age at the time of operation averaged 10.9 years (range 5-14 years). The time from injury to operation ranged from 1 to 6 years (average 3.2 years). Means of the carrying angle of the deformed and the normal side were - 19.6” and 6.5” respectively. Means of the HEW angles of the deformed and the normal sides were - 18.8” and 7.7” respectively. There was no significant correlation between the degree of MRD and the degree of varus deformity measured by using the CA or the HEW angles of the deformed side (correlation coefficients r= - 0.08 and - 0.02). There was also no significant correlation between the degree of MRD and the difference between the CA or the HEW angles of the deformed side and the CA or HEW angles of the normal side, respectively (r = 0.0217 and 0.044, respectively).
H-E-Wangles
(“)
D
N
(N-D)
MRD
z 5 5 5 5 5 7 7 5
-25 -18 -22 -18 -12 -13 -26 -26 -16 -12 -22 -24 -15 -6 -16 -27 -20 -22 -20 -22 -18 -15 -18
10 8 7 7 10 10 11 7 8 8 8 7 10 5 8 6 8 7 5 5 7 8 7
(35) (26) (29) (25) (22) (23) (37) (33) (24) (20) (30) (31) (25) (11) (24) (33) (28) (29) (25)
10 22 15 20 27 0 15 18 25 0 11 15 8 22 34 24 9 32 0 13 16 30 8
6.5
- 18.8
(N-D)
7.7
(27) (25) (23) (25) (26.5)
16.2
MRD = medial rotational deformity.
correct the varus deformity, even in children, without waiting for closure of the epiphyseal plate of the distal humerus. This has made it possible to conduct this study, because the corrective osteotomy is performed soon after the injury. As our method of corrective osteotomy is performed in the supracondylar region, studying the rotational deformity from the cut surface at the osteotomy site is most helpful in documenting the actual rotational deformity. The old posterior border can be differentiated from that of the newly formed posterior border intraoperatively when the deformity is operated on soon after the injury and before remodelling masks the native bone. The findings can be used to trace the fracture alignment that existed previously in this area. Although medial rotational deformity is usually associated with cubitus varus deformity, the results show no correlation between the degree of rotational deformity and that of the varus deformity. It is therefore probable that the severity of malrotation of the supracondylar fracture does not contribute to the severity of the varus deformity of the elbow.
Acknowledgements Discussion Cubitus varus deformity is a common elbow deformity among children in Thailand. The deformity usually results from poor treatment of the supracondylar fracture by bone-setters. The fracture is not usually reduced and is held with the elbow in extension using the multiple-strip bamboo splint. Most of our patients seek treatment to correct the cubitus varus a few years later, after they have realized that the deformity does not regress with time. It is our policy to
We thank Mr David Narot for editorial assistance.
References Langenskiold A. and Kivilaakso R. (1967) Varus and valgus deformity of the elbow following supracondylar fracture of the humerus. Acfa Orfhop. Scand. 38,313.
418
Injury: International Journal of the Care of the Injured (1993) Vol. 24/No.
Laupattarakasem W., Mahaisavariya B., Kowsuwon W. et al. (1989) Pentalateral osteotomy for cubitus varus: clinical experiences of a new technique. ]. Bane]oint Surg. 71B,667. Oppenheim W. L., Clader T. J. Smith C. et al. (1984) Supracondylar humeral osteotomy for traumatic childhood cubitus varus deformity. Clin. orthop. 188,34. Smith L. (1960) Deformity following supracondylar fractures of the humerus. J. Bone Joint Surg. 42A, 235. Wilkin K. E. (1990) Residuals of elbow trauma in children. Orthop. Clin. North Am. 21,291.
6
Yamamoto I., Ishii S., Usui M. et al. (1985) Cubitus varus deformity following supracondylar fracture of the humerus: a method for measuring rotational deformity. Clin. Or&p. 201,179. Paper accepted
20 November
1992.
Requests for reprints should be addressed to: B. Mahaisavariya MD, Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand.