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A 10 yr old boy with trauma to right elbow 2 yrs back now has gun stock deformity with 30° flexion deformity with further flexion possible supination pronation complete with increased internal rotation at shoulder by Yamamoto test with disturbed 3 point bony prominence relationship (medial limb short) differentials and treatment

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pediatric cubitus varus deformity treatment corrective osteotomy late complication supracondylar fracture

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cubitus varus gunstock deformity child elbow clinical photograph radiograph

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PMID: 38375863

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https://pmc.ncbi.nlm.nih.gov/articles/PMC5427392

Likely diagnosis

Post-traumatic cubitus varus (gun-stock deformity) of the right elbow, with a multiplanar distal humeral malunion following childhood elbow trauma.
The positive Yamamoto test indicates an internal-rotation component, which commonly accompanies cubitus varus after malunion. The usual deformity components are:
  • Varus of the distal humerus
  • Internal rotation of the distal fragment
  • Sagittal-plane deformity, often extension, though this child has a 30-degree flexion contracture/deformity
Cubitus varus is most often due to a malunited extension-type supracondylar humeral fracture, not a growth disturbance. S Das: A Manual on Clinical Surgery, p. 969, defines cubitus varus as reduction or reversal of the normal carrying angle. Campbell notes that distal-humeral malunion can follow pediatric supracondylar fractures and may cause later mechanical problems, not merely cosmetic deformity. Campbell's Operative Orthopaedics, 15th ed., p. 8357.

Important diagnostic concern in this case

In simple supracondylar malunion, the three bony-point relationship is preserved, because the deformity is extra-articular.
Here, the three-point relationship is disturbed, with a short medial limb. This is atypical for an isolated supracondylar malunion and suggests an injury involving the medial distal humerus or elbow joint, particularly a malunited/nonunited medial condyle fracture.

Differentials

  1. Malunited supracondylar fracture of humerus
    • Most common cause of cubitus varus.
    • Varus, internal rotation, and sagittal angulation.
    • Bony-point relationship should remain normal.
    • Most likely explanation for the gun-stock appearance and positive Yamamoto test, but does not explain the altered triangle well.
  2. Malunion or nonunion of medial condyle fracture of humerus
    • Strong differential here because the medial side of the olecranon-epicondylar triangle is shortened/disturbed.
    • May produce varus, flexion deformity, altered joint congruity, and possible instability.
    • Needs careful radiographic assessment because medial condyle fractures are intra-articular.
  3. Old neglected elbow dislocation or fracture-dislocation
    • Can cause fixed flexion deformity and disturbed olecranon-epicondylar relationship.
    • Radiographs will show persistent ulnohumeral incongruity or secondary joint changes.
  4. Malunited lateral condyle fracture
    • Can cause a carrying-angle deformity, but more often valgus rather than varus.
    • Consider if radiographs show lateral condylar malunion, fishtail deformity, or trochlear growth disturbance.
  5. Distal-humeral physeal injury, trochlear osteonecrosis, or partial growth arrest
    • Less common.
    • May produce progressive deformity and articular incongruity.
    • Campbell describes distal-humeral osteonecrosis/growth abnormality as a rare cause of progressive cubitus varus after injury. Campbell's Operative Orthopaedics, 15th ed., p. 8357.

Investigations

  1. Plain radiographs of both elbows
    • AP and lateral views.
    • Compare with the normal side.
    • Assess:
      • Carrying angle
      • Humerus-elbow-wrist angle
      • Baumann angle
      • Lateral condyle prominence
      • Alignment of the radiocapitellar and ulnohumeral joints
      • Union/nonunion or malunion of medial condyle/epicondyle
      • Trochlear shape and physeal disturbance
  2. CT scan with 3D reconstruction
    • Particularly indicated here because this appears to be a multiplanar deformity and the bony triangle is abnormal.
    • Defines varus, internal rotation, flexion/extension deformity, articular congruity, and any medial-condyle malunion.
  3. Neurovascular assessment
    • Specifically examine ulnar nerve function and check for snapping/dislocation of the ulnar nerve or medial triceps.
    • Cubitus varus can later be associated with lateral instability, secondary lateral condyle fracture, snapping triceps, and ulnar neuropathy. Campbell's Operative Orthopaedics, 15th ed., pp. 8357-60.

Treatment

If radiographs confirm extra-articular supracondylar malunion with a congruent elbow

Corrective distal humeral osteotomy is indicated if there is:
  • Significant cosmetic concern
  • Functional limitation, including the 30-degree flexion deformity
  • Progressive deformity
  • Instability, pain, or neurological symptoms
  • Marked rotational deformity
At age 10, the deformity will not reliably remodel. Correct varus, sagittal deformity, and internal rotation together.
Osteotomy options
  • Lateral closing-wedge osteotomy, also called French osteotomy
  • Dome osteotomy
  • Step-cut osteotomy
  • Three-dimensional corrective osteotomy with plate fixation or patient-specific guides for substantial rotational/multiplanar deformity
The operation should be planned from bilateral radiographs and preferably 3D CT in this child. The target is restoration of a near-normal carrying angle, correction of internal rotation, and correction of the flexion/extension component.
A 2024 systematic review of 911 children found that lateral closing-wedge osteotomy was the commonest and technically simpler method for one-plane correction; three-dimensional osteotomy had favorable results for multidimensional deformities. The review also reported lateral-condylar prominence in 5.56% after lateral closing-wedge osteotomy. Systematic review of operative techniques

If medial condyle malunion/nonunion or an intra-articular deformity is confirmed

This is not simply a cosmetic cubitus-varus osteotomy case.
Management should be by a pediatric upper-limb orthopedic surgeon and may require:
  • Open reduction and internal fixation if a reconstructable nonunion exists
  • Corrective osteotomy combined with restoration of joint congruity
  • Bone grafting if nonunion is present
  • Ulnar nerve identification, decompression, or transposition when indicated
  • Treatment of associated instability or contracture
In a severe longstanding incongruent elbow, the realistic aims may be pain relief, stability, and functional arc rather than a perfectly normal radiograph.

Flexion deformity

A 30-degree flexion deformity should be assessed separately:
  • If due to the bony sagittal deformity, correct it during the osteotomy.
  • If due to soft-tissue contracture, gradual stretching/physiotherapy may be attempted for a mild component, but a two-year fixed deformity often needs contracture release only if it remains functionally limiting after bony correction.
Bottom line: The working diagnosis is post-traumatic cubitus varus with internal rotation, but the disturbed three-point relationship and short medial limb make medial condyle malunion/nonunion or old fracture-dislocation an essential exclusion before planning a corrective osteotomy.

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mkdir -p "/tmp/workspace/cubitus-varus-quick-reference/output"  python - <<'PY' from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.enums import TA_CENTER from reportlab.lib.units import cm from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, KeepTogether from reportlab.pdfbase.ttfonts import TTFont from reportlab.pdfbase import pdfmetrics from reportlab.lib.colors import HexColor from pathlib import Path out = Path('/tmp/workspace/cubitus-varus-quick-reference/output/Cubitus_Varus_Evaluation_Quick_Reference.pdf') NAVY=HexColor('#123B5D'); BLUE=HexColor('#DCECF7'); TEAL=HexColor('#0D6B72'); RED=HexColor('#A52A2A'); PALE=HexColor('#F5F8FA'); GOLD=HexColor('#FCE9B5'); GRAY=HexColor('#555555') styles=getSampleStyleSheet() styles.add(ParagraphStyle(name='Title2', parent=styles['Title'], fontName='Helvetica-Bold', fontSize=19, leading=23, textColor=NAVY, alignment=TA_CENTER, spaceAfter=4)) styles.add(ParagraphStyle(name='Sub', parent=styles['Normal'], fontName='Helvetica', fontSize=8.5, leading=11, textColor=GRAY, alignment=TA_CENTER, spaceAfter=10)) styles.add(ParagraphStyle(name='H', parent=styles['Heading2'], fontName='Helvetica-Bold', fontSize=10.5, leading=13, textColor=colors.white, backColor=NAVY, borderPadding=(4,6,4,6), spaceBefore=7, spaceAfter=5)) styles.add(ParagraphStyle(name='B', parent=styles['BodyText'], fontName='Helvetica', fontSize=8.25, leading=10.4, spaceAfter=2)) styles.add(ParagraphStyle(name='Small', parent=styles['BodyText'], fontName='Helvetica', fontSize=7.35, leading=9.1, textColor=GRAY)) styles.add(ParagraphStyle(name='Box', parent=styles['BodyText'], fontName='Helvetica-Bold', fontSize=8.5, leading=11, textColor=NAVY)) def P(t, style='B'): return Paragraph(t, styles[style]) def bullet(t): return P('• '+t) def section(title, items): return [P(title,'H')] + items doc=SimpleDocTemplate(str(out),pagesize=A4,rightMargin=1.15*cm,leftMargin=1.15*cm,topMargin=0.85*cm,bottomMargin=0.8*cm) story=[] story += [P('CUBITUS VARUS: EVALUATION QUICK REFERENCE','Title2'), P('Child with post-traumatic gun-stock deformity | Clinical assessment, imaging, red flags, and planning checklist','Sub')] alert=Table([[P('<b>Working definition:</b> Decreased or reversed carrying angle after elbow trauma, usually from distal-humeral malunion. It is commonly a multiplanar deformity: coronal varus + internal rotation + sagittal-plane angulation.','Box')]], colWidths=[18.7*cm]) alert.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),BLUE),('BOX',(0,0),(-1,-1),0.6,TEAL),('LEFTPADDING',(0,0),(-1,-1),8),('RIGHTPADDING',(0,0),(-1,-1),8),('TOPPADDING',(0,0),(-1,-1),6),('BOTTOMPADDING',(0,0),(-1,-1),6)])) story += [alert, Spacer(1,5)] story += section('1. HISTORY', [ bullet('<b>Index injury:</b> age, side, mechanism, initial diagnosis, treatment, reduction/pinning, complications, and old radiographs.'), bullet('<b>Course:</b> onset and progression of deformity; change with growth; prior physiotherapy or surgery.'), bullet('<b>Symptoms:</b> pain, weakness, clicking/snapping, recurrent instability, limitation in sport/ADLs, paraesthesia in ulnar distribution.'), bullet('<b>Patient goal:</b> appearance, function, pain, instability, or neurological symptoms.'), ]) story += section('2. EXAMINATION: DO BOTH SIDES', [ bullet('<b>Inspect standing, arms fully extended and forearms supinated:</b> compare carrying angle, arm-forearm axis, scars, swelling, muscle wasting, and lateral condylar prominence.'), bullet('<b>Measure:</b> carrying angle with elbow extended and supinated. It normally disappears with flexion or pronation. Record side-to-side difference.'), bullet('<b>ROM:</b> flexion-extension arc; pronation-supination; document fixed flexion/extension deformity.'), bullet('<b>Rotation:</b> assess distal-humeral internal rotation. A positive Yamamoto test, with increased apparent shoulder internal rotation, supports internal-rotation malunion.'), bullet('<b>Palpate:</b> medial/lateral epicondyle, olecranon, joint line, distal humerus; look for snapping medial triceps or ulnar nerve.'), bullet('<b>Neurovascular:</b> ulnar nerve motor/sensation, median/AIN and radial/PIN function, pulses and perfusion.'), bullet('<b>Stability:</b> assess lateral collateral ligament complex / posterolateral rotatory instability if pain, apprehension, or giving way.'), ]) red=Table([[P('<b>Key discriminator:</b> In an uncomplicated extra-articular supracondylar malunion, the olecranon and epicondylar three-point relationship should be preserved. A disturbed triangle, shortened medial limb, or joint incongruity suggests intra-articular injury, especially medial condyle malunion/nonunion, or old fracture-dislocation.','B')]], colWidths=[18.7*cm]) red.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),HexColor('#FBE5E5')),('BOX',(0,0),(-1,-1),0.6,RED),('LEFTPADDING',(0,0),(-1,-1),8),('RIGHTPADDING',(0,0),(-1,-1),8),('TOPPADDING',(0,0),(-1,-1),6),('BOTTOMPADDING',(0,0),(-1,-1),6)])) story += [red] story += section('3. DIFFERENTIAL DIAGNOSIS', [ bullet('<b>Most likely:</b> malunited extension-type supracondylar humeral fracture.'), bullet('<b>Must exclude when bony triangle is abnormal:</b> medial condyle fracture malunion/nonunion; old elbow fracture-dislocation.'), bullet('<b>Other causes:</b> lateral condyle malunion, distal-humeral physeal arrest, trochlear osteonecrosis/fishtail deformity, congenital cubitus varus, pseudo-varus from altered distal-humeral width.'), ]) story += section('4. IMAGING', [ bullet('<b>First line:</b> bilateral AP and true lateral elbow radiographs. Obtain full extension AP where tolerated; compare with contralateral side.'), bullet('<b>On AP:</b> carrying angle, humerus-elbow-wrist angle, Baumann (humerocapitellar) angle, distal-humeral width, epicondylar symmetry, union/malunion, and joint congruity.'), bullet('<b>On lateral:</b> flexion/extension component, anterior humeral line, radiocapitellar alignment, ulnohumeral congruity, osteophytes/heterotopic bone.'), bullet('<b>CT with 3D reconstruction:</b> for multiplanar deformity, doubtful condylar union, altered bony triangle, intra-articular malunion, or preoperative planning.'), bullet('<b>MRI/US selectively:</b> cartilage/physeal pathology, ulnar nerve or snapping triceps, and suspected ligament injury.'), ]) story += section('5. DOCUMENT THE DEFORMITY', [ bullet('Coronal: varus/valgus and side-to-side carrying-angle or HEW-angle difference.'), bullet('Sagittal: fixed flexion or extension deformity; flexion-extension arc.'), bullet('Axial: internal/external rotation component, including Yamamoto-test finding.'), bullet('Joint status: congruent vs incongruent; condylar union; physeal/trochlear morphology.'), bullet('Function: pain, instability, nerve signs, cosmesis, limitation of daily activity/sport.'), ]) story += section('6. MANAGEMENT TRIAGE', [ bullet('<b>Observe/reassure:</b> mild stable deformity, congruent painless elbow, full/acceptable function, no neurological or instability symptoms. Counsel that established bony deformity has limited spontaneous correction.'), bullet('<b>Refer for pediatric upper-limb orthopedic assessment:</b> meaningful cosmetic concern, loss of motion, pain, instability, progressive deformity, neurological symptoms, or suspected intra-articular malunion/nonunion.'), bullet('<b>Corrective osteotomy:</b> for symptomatic or unacceptable extra-articular malunion. Plan correction in all relevant planes and restore alignment close to the opposite side.'), bullet('<b>Intra-articular/medial-condyle pathology:</b> requires individualized reconstruction, possible fixation/bone grafting plus osteotomy, and ulnar nerve evaluation. Do not treat as a simple cosmetic osteotomy without defining the anatomy.'), ]) story += section('7. PREOPERATIVE CHECKLIST', [ bullet('☐ Bilateral standardized radiographs reviewed ☐ deformity measured in 3 planes ☐ contralateral template available'), bullet('☐ CT-3D if anatomy/rotation/articular congruity uncertain ☐ nerve and instability assessment documented'), bullet('☐ Family goals, scar/lateral-prominence risks, residual deformity, stiffness, infection, nerve injury, and fixation plan discussed.'), ]) story += [Spacer(1,4), P('<b>Sources:</b> S Das, <i>A Manual on Clinical Surgery</i>, 13th ed., pp. 963-74. Campbell\'s <i>Operative Orthopaedics</i>, 15th ed., pp. 8357-60. Hoffman et al., systematic review of operative techniques for pediatric cubitus varus, PMID 38375863 (2024). This aid supports, but does not replace, specialist assessment and imaging review.','Small')] doc.build(story) print(out) PY

Running Command

python - <<'PY' from pathlib import Path from pypdf import PdfReader p=Path('/tmp/workspace/cubitus-varus-quick-reference/output/Cubitus_Varus_Evaluation_Quick_Reference.pdf') print('exists=',p.exists(),'bytes=',p.stat().st_size if p.exists() else 0) r=PdfReader(str(p)) print('pages=',len(r.pages)) for i,page in enumerate(r.pages,1): text=page.extract_text() or '' print(i, len(text), text[:90].replace('\n',' | ')) PY

Running Command

mkdir -p "/tmp/workspace/cubitus-varus-quick-reference/output" && python - <<'PY' from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.enums import TA_CENTER from reportlab.lib.units import cm from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle from reportlab.lib.colors import HexColor from pathlib import Path out=Path('/tmp/workspace/cubitus-varus-quick-reference/output/Cubitus_Varus_Evaluation_Quick_Reference.pdf') NAVY=HexColor('#123B5D'); BLUE=HexColor('#DCECF7'); TEAL=HexColor('#0D6B72'); RED=HexColor('#A52A2A'); GRAY=HexColor('#555555') s=getSampleStyleSheet() s.add(ParagraphStyle(name='Title2',parent=s['Title'],fontName='Helvetica-Bold',fontSize=19,leading=23,textColor=NAVY,alignment=TA_CENTER,spaceAfter=4)) s.add(ParagraphStyle(name='Sub',parent=s['Normal'],fontName='Helvetica',fontSize=8.5,leading=11,textColor=GRAY,alignment=TA_CENTER,spaceAfter=10)) s.add(ParagraphStyle(name='H',parent=s['Heading2'],fontName='Helvetica-Bold',fontSize=10.5,leading=13,textColor=colors.white,backColor=NAVY,borderPadding=(4,6,4,6),spaceBefore=7,spaceAfter=5)) s.add(ParagraphStyle(name='B',parent=s['BodyText'],fontName='Helvetica',fontSize=8.25,leading=10.4,spaceAfter=2)) s.add(ParagraphStyle(name='Small',parent=s['BodyText'],fontName='Helvetica',fontSize=7.35,leading=9.1,textColor=GRAY)) s.add(ParagraphStyle(name='Box',parent=s['BodyText'],fontName='Helvetica-Bold',fontSize=8.5,leading=11,textColor=NAVY)) def P(t,style='B'): return Paragraph(t,s[style]) def bullet(t): return P('• '+t) def sec(t, rows): return [P(t,'H'),*rows] story=[P('CUBITUS VARUS: EVALUATION QUICK REFERENCE','Title2'),P('Child with post-traumatic gun-stock deformity | Clinical assessment, imaging, red flags, and planning checklist','Sub')] def callout(text,bg,border): t=Table([[P(text,'Box')]],colWidths=[18.7*cm]);t.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),bg),('BOX',(0,0),(-1,-1),0.6,border),('LEFTPADDING',(0,0),(-1,-1),8),('RIGHTPADDING',(0,0),(-1,-1),8),('TOPPADDING',(0,0),(-1,-1),6),('BOTTOMPADDING',(0,0),(-1,-1),6)]));return t story += [callout('<b>Working definition:</b> Decreased or reversed carrying angle after elbow trauma, usually from distal-humeral malunion. It is commonly a multiplanar deformity: coronal varus + internal rotation + sagittal-plane angulation.',BLUE,TEAL),Spacer(1,5)] story += sec('1. HISTORY',[bullet('<b>Index injury:</b> age, side, mechanism, initial diagnosis, treatment, reduction/pinning, complications, and old radiographs.'),bullet('<b>Course:</b> onset and progression of deformity; change with growth; prior physiotherapy or surgery.'),bullet('<b>Symptoms:</b> pain, weakness, clicking/snapping, recurrent instability, limitation in sport/ADLs, paraesthesia in ulnar distribution.'),bullet('<b>Patient goal:</b> appearance, function, pain, instability, or neurological symptoms.')]) story += sec('2. EXAMINATION: DO BOTH SIDES',[bullet('<b>Inspect standing, arms fully extended and forearms supinated:</b> compare carrying angle, arm-forearm axis, scars, swelling, muscle wasting, and lateral condylar prominence.'),bullet('<b>Measure:</b> carrying angle with elbow extended and supinated. Record side-to-side difference.'),bullet('<b>ROM:</b> flexion-extension arc; pronation-supination; document fixed flexion/extension deformity.'),bullet('<b>Rotation:</b> assess distal-humeral internal rotation. A positive Yamamoto test, with increased apparent shoulder internal rotation, supports internal-rotation malunion.'),bullet('<b>Palpate:</b> medial/lateral epicondyle, olecranon, joint line, distal humerus; look for snapping medial triceps or ulnar nerve.'),bullet('<b>Neurovascular and stability:</b> ulnar, median/AIN, radial/PIN function; pulses; assess lateral collateral ligament/posterolateral rotatory instability when indicated.')]) story += [callout('<b>Key discriminator:</b> In an uncomplicated extra-articular supracondylar malunion, the olecranon and epicondylar three-point relationship should be preserved. A disturbed triangle, shortened medial limb, or joint incongruity suggests intra-articular injury, especially medial condyle malunion/nonunion, or old fracture-dislocation.',' #FBE5E5'.strip(),RED)] story += sec('3. DIFFERENTIAL DIAGNOSIS',[bullet('<b>Most likely:</b> malunited extension-type supracondylar humeral fracture.'),bullet('<b>Must exclude when bony triangle is abnormal:</b> medial condyle fracture malunion/nonunion; old elbow fracture-dislocation.'),bullet('<b>Other causes:</b> lateral condyle malunion, distal-humeral physeal arrest, trochlear osteonecrosis/fishtail deformity, congenital cubitus varus, pseudo-varus from altered distal-humeral width.')]) story += sec('4. IMAGING',[bullet('<b>First line:</b> bilateral AP and true lateral elbow radiographs. Obtain full-extension AP where tolerated; compare with the contralateral side.'),bullet('<b>AP:</b> carrying angle, humerus-elbow-wrist angle, Baumann angle, distal-humeral width, epicondylar symmetry, union/malunion, and joint congruity.'),bullet('<b>Lateral:</b> flexion/extension component, anterior humeral line, radiocapitellar alignment, ulnohumeral congruity, osteophytes/heterotopic bone.'),bullet('<b>CT with 3D reconstruction:</b> multiplanar deformity, doubtful condylar union, altered bony triangle, intra-articular malunion, or preoperative planning.'),bullet('<b>MRI/US selectively:</b> cartilage/physeal pathology, ulnar nerve or snapping triceps, suspected ligament injury.')]) story += sec('5. DOCUMENT THE DEFORMITY',[bullet('Coronal: varus/valgus and side-to-side carrying-angle or HEW-angle difference.'),bullet('Sagittal: fixed flexion or extension deformity; flexion-extension arc.'),bullet('Axial: internal/external rotation component, including Yamamoto-test finding.'),bullet('Joint status: congruent vs incongruent; condylar union; physeal/trochlear morphology.'),bullet('Function: pain, instability, nerve signs, cosmesis, activity/sport limitation.')]) story += sec('6. MANAGEMENT TRIAGE',[bullet('<b>Observe/reassure:</b> mild stable deformity, congruent painless elbow, acceptable function, no neurological or instability symptoms.'),bullet('<b>Refer for pediatric upper-limb orthopedic assessment:</b> meaningful cosmetic concern, loss of motion, pain, instability, progressive deformity, neurological symptoms, or suspected intra-articular malunion/nonunion.'),bullet('<b>Corrective osteotomy:</b> symptomatic or unacceptable extra-articular malunion. Plan correction in all relevant planes and restore alignment close to the opposite side.'),bullet('<b>Intra-articular/medial-condyle pathology:</b> individualized reconstruction, possible fixation/bone grafting plus osteotomy, and ulnar nerve evaluation. Do not treat as a simple cosmetic osteotomy without defining anatomy.')]) story += sec('7. PREOPERATIVE CHECKLIST',[bullet('☐ Bilateral standardized radiographs reviewed ☐ deformity measured in 3 planes ☐ contralateral template available'),bullet('☐ CT-3D if anatomy/rotation/articular congruity uncertain ☐ nerve and instability assessment documented'),bullet('☐ Family goals, scar/lateral-prominence risks, residual deformity, stiffness, infection, nerve injury, and fixation plan discussed.')]) story += [Spacer(1,4),P('<b>Sources:</b> S Das, <i>A Manual on Clinical Surgery</i>, 13th ed., pp. 963-74. Campbell\'s <i>Operative Orthopaedics</i>, 15th ed., pp. 8357-60. Hoffman et al., systematic review of operative techniques for pediatric cubitus varus, PMID 38375863 (2024). Educational aid only: supports, but does not replace, specialist assessment and imaging review.','Small')] doc=SimpleDocTemplate(str(out),pagesize=A4,rightMargin=1.15*cm,leftMargin=1.15*cm,topMargin=.85*cm,bottomMargin=.8*cm) doc.build(story) print(out) PY python - <<'PY' from pathlib import Path from pypdf import PdfReader p=Path('/tmp/workspace/cubitus-varus-quick-reference/output/Cubitus_Varus_Evaluation_Quick_Reference.pdf') print('exists=',p.exists(),'bytes=',p.stat().st_size) r=PdfReader(str(p)); print('pages=',len(r.pages),'chars=',sum(len(pg.extract_text() or '') for pg in r.pages)) PY

Cubitus Varus Evaluation Quick Reference

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Unilateral talipes equino cavovarus deformity with planter upgoing with delayed milestones but normal IQ

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"cerebral palsy" AND equinovarus

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unilateral equinocavovarus upgoing plantar delayed milestones normal intelligence spastic hemiplegic cerebral palsy evaluation

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spastic hemiplegic cerebral palsy equinovarus foot child clinical illustration

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https://www.ncbi.nlm.nih.gov/books/NBK533221

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PMID: 40540630

This pattern is most suggestive of spastic hemiplegic cerebral palsy, affecting the side of the unilateral equino-cavovarus foot.

Why

  • Upgoing plantar response indicates an upper motor neuron lesion.
  • Unilateral equinovarus is most commonly seen in spastic hemiplegia, due to overactivity of tibialis anterior and/or tibialis posterior with heel-cord spasticity/contracture. Miller's Review of Orthopaedics, 9th ed., pp. 6106-22.
  • Delayed motor milestones with preserved IQ is compatible with mild unilateral CP. Cognitive impairment is not required for CP.
  • A cavovarus component reflects chronic muscle imbalance.

Important differentials

Do not label it CP without excluding a structural neuraxial cause, especially with unilateral cavus/cavovarus:
  1. Spastic hemiplegic cerebral palsy from a remote perinatal stroke or other non-progressive brain injury.
  2. Spinal cord lesion: tethered cord, syrinx, intramedullary tumor, or other myelopathy.
  3. Brain lesion: old stroke, malformation, tumor, or inflammatory lesion.
  4. Hereditary neuropathy, especially Charcot-Marie-Tooth disease: typically bilateral, with distal weakness, reduced/absent reflexes and downgoing plantar responses, so less likely here.
  5. Less likely: post-polio deformity, myelomeningocele, or focal peripheral nerve disease. These are generally lower motor neuron patterns, not an extensor plantar response.
Up to two-thirds of cavus feet have a neurological cause, and unilateral cavus specifically warrants full neurological examination and MRI of the neuraxis. Miller's Review of Orthopaedics, 9th ed., pp. 4235-64.

Assessment

  • Full neurological exam: tone, power, deep-tendon reflexes, clonus, superficial abdominal reflexes, plantar responses, sensory level, spine and bladder/bowel symptoms.
  • Check for subtle upper-limb involvement on the same side: hand preference, reduced dexterity, pronator/flexor posturing, hyperreflexia.
  • Observe gait: equinus, varus in stance/swing, toe walking, knee pattern.
  • Foot evaluation: passive ankle dorsiflexion with knee flexed and extended, hindfoot flexibility, forefoot-driven vs fixed hindfoot varus using the Coleman block test.
  • Standing AP/lateral foot radiographs.
  • MRI brain and whole spine/neuraxis, with pediatric neurology referral. Brain MRI often identifies the cause in suspected unilateral CP; spine imaging is particularly important with unilateral cavus.
  • Physiotherapy and gait analysis if available.

Management principles

  • Early multidisciplinary care: pediatric neurology, pediatric orthopedics, physiotherapy, occupational therapy, and orthotics.
  • Flexible equinus/equinovarus: stretching program, AFO, serial casting, and selected botulinum toxin for focal spasticity.
  • Persistent dynamic varus in ambulatory hemiplegia: consider split tibialis anterior or split posterior tibialis transfer, with Achilles/gastrocnemius lengthening only when a true fixed equinus contracture is documented.
  • Fixed cavovarus: individualized soft-tissue and, if needed, bony correction after defining the neurological diagnosis and gait mechanics.
Recent evidence supports split posterior tibialis tendon transfer as an option for selected ambulatory children with CP-related equinovarus, though recurrence occurs and patient selection matters. A 2025 systematic review found lower failure rates in ambulatory hemiplegic children than in nonambulatory quadriplegic children (PubMed review).
Working diagnosis: unilateral spastic hemiplegic CP with spastic equino-cavovarus foot, but obtain MRI brain and neuraxis before treating this as an isolated foot deformity.
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