Cubitus varus or “gunstock” deformity, a common long term complication of a supracondylar fracture [1]. Cubitus vams deformity is not a functional problem, but it may become so disfiguring that correction is indicated. Cubitus varus deformity is the most common late complication after supracondylar fracture of the distal humerus in children, incidence varying from 4% to 58% [2,3]. The metaphyseal area of the distal humerus is the weakest region around the elbow, so supracondylar fractures are the most common elbow injuries.

Also, the frequent falls in small children while playing, cycling or fall inside the house from bed, the sofa has added to the increase in incidence. The non-dominant side and boys have a more predilection to such injuries than the dominant side and girls. Associated vascular injuries in 1% of the cases and nerve injuries involving median and radial nerve in at least 7% of the cases add to the concern [4,5]. It occurs in only the extension type of supracondylar fracture of the humerus, causing a reduction or loss of the carrying angle. Components of cubitus varus deformity are: a) medial angulation, b)

medial rotation, c) extension of distal fragment with or without d) medial epicondyle epiphyseal injury leading to delayed growth of medial condyle and cubitus varus deformity [6]. Many surgical techniques to correct cubitus varus deformity are described in the literature [7-9]. These include opening wedge, closing wedge and three-dimensional osteotomies and reverse ‘V’ osteotomy [10-16]. Closed wedge osteotomy is easy to perform but it leads to lateral condyle prominence, inadequate removal of wedge and shortening. Medial opening wedge osteotomy is associated with stretching of ulnar nerve and instability and needs for bone graft and difficulty in fixation.

Three dimensional osteotomy is difficult to perform but among all the surgical treatments available, dome osteotomy can realign the distal fragment in horizontal and coronal plane both. The residual prominence of the lateral condyle and loss of elbow rotation is avoided [17]. Although, dome osteotomy has been described by Tachdjianin 1972, however, there is not enough clinical evidence available. This was followed by Higaki T and Ikuta Y who reported this procedure [18]. considering the advantages of dome osteotomy, we did a study and evaluated the results of dome osteotomy.

A midline posterior incision was given andParatriceps approach was used. The ulnar nerve was identified, exposed proximally and protected with wet gauze during the operation. Pericondrium and the periosteum junction and was identified in the distal humerus. A thick portion of the periosteum was detached carefully to avoid trauma topericondriumand physis. A preoperatively drawn template was placed over the posterior aspect of the humerus to match the OA line with the periosteum-perichondrium junction of the distal humerus of the lateral side. Point ‘A’, point ‘B’ and the dome of the osteotomy were then marked. During the osteotomy the neurovascular bundles in the anterior cubital fossa were protected carefully. Multiple drill holes were made along with the marked osteotomy arc by drilling through the anterior and posterior cortices of the humerus and osteotomy was completed with an arrow osteotome.

The distal fragment was then rotated along the arc till point ‘A’ and point ‘B’ are overlapping. The elbow gets realigned as planned. Percutaneous cross ‘K’ wire fixation for the osteotomy was done. The ‘K’ wires were bent and kept protruding through the skin for easy removal later. The wound was closed in layers and the padded dressing was given. Plaster of Paris back slab was applied. Intravenous antibiotics were given, 6 hours before surgery and for the next two days in the post-operative period and further 5 days oral antibiotics were given. Postoperatively, active exercises of the fingers and wrist were encouraged from the first postoperative day.

Stitches were removed after 2 weeks. The plaster of the Paris back slab was removed after 3 weeks and the ‘K’ wires were removed after 5 weeks. Gentle active movements of the elbow were encouraged.

Cubitus varus is one of the most common complications of supracondylar fracture of humerus in children treated with non-operative management without reduction and fixation, the incidence of which varies from 4% to 58%.

Most of the patients in this series were mainly the result of this practice. All the cases were treated conservatively with no history of any associated injuries. The majority of cases in the present study were males though some studies have suggested an equal incidence between males and females. Yet studies from the Indian subcontinent generally have a higher prevalence of males as compared to females in both childhood and adult cases. It has been reported that the incidence of cubitus varus is high in fractures that are treated conservatively. In the present study, the left side was more commonly involved as compared to the right side. This is following the reported classical feature of the supracondylar fractures which mostly occurs in the non-dominant limb. In the present study, preoperative lateral condylar prominence index (LCPI) values ranged from -8.4 to 5.9%.

Preoperative LCPI has been reported to vary from -67% to +20.8% in the literature [19-21]. The high variability in the average value of LCPI is because it is noted with the sign, and on averaging sometimes values with opposite signs change to provide a poor idea of the actual magnitude of the problem. Thus we find that the average LCPI does not provide a good idea of the extent of the problem when depicted through an average value, hence, it is time now to build a consensus and evolve a strategy to compensate for this problem. We suggest a method to average the square root of squared LCPI values of individual patients and report the LCPI in ± terms. This is a suggestion made through this work on which consensus needs to be built. Prospective multi-centre studies are needed to further evaluate the safety and efficacy of this treatment alternative.

Dome osteotomy is a relatively technically demanding technique for correction of cubitus varus deformity but with a better functional outcome without being associated with lateral condyle prominence.

Excellent results in the present research attributed to thorough preoperative planning and meticulous intraoperative procedure along with percutaneous technique and mini external fixator used which gave stable fixation for early rehabilitation.