Results of assessment of the carrying angle of the elbow: A clinical and radiographic study
Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
RESULTS OF ASSESSMENT OF THE CARRYING ANGLE OF
THE ELBOW: A CLINICAL AND RADIOGRAPHIC STUDY
Do Viet Tuyen1, Dao Xuan Tich2
SUMMARY
Objectives: To assess the elbow carrying angle in normal children using clinic and
radiographic examinations, to determine the range of normality from 6 to 15 years old, and to
see whether there is a statistically significant difference between the clinical and radiographic
measurements. Subjects and methods: We conducted a clinical examination and took some
X-rays of the elbow joint on both sides in 300 volunteers (600 elbows) ranging from 6 to
15 years old, who were divided into age groups with a 1-year interval. The angle created by the
long axis of the humerus and the forearm was determined during a radiographic examination of
the elbow. The student t-test, Wilcoxon test, and Mann - Whitney test were used to statistically
analyze the results. Results: Females had an average clinical elbow carrying angle of
9.42° 1.23, while males had an average clinical elbow carrying angle of 9.29° 1.33. From the
age of six to sixteen, the values gradually rise. The clinical and radiographic assessments did
not vary statistically. Conclusion: The elbow carrying angle increases progressively from 6 until
16 years. There was no statistical difference between the clinical and radiographic measurements.
Studying the elbow carrying angle in children aged 6 to 15 years is very useful in the treatment
of cubitus varus deformity.
* Keywords: Elbow carrying angle; Cubitus varus deformity.
INTRODUCTION
in Vietnam, there is no research on the
angle of the elbow in children. Therefore,
our study aims: To assess the elbow
carrying angle in normal children using
clinic and radiographic examinations, to
determine the range of normality from 6 to
15 years old, and to see whether there is
a statistically significant difference between
the clinical and radiographic measurements.
Then, we could apply those results for
treating, following the results of the treatment
of cubitus varus in children.
The assessment of the elbow carrying
angle is particularly important to treat and
follow traumatic lesions affecting the
pediatric elbow [1]. This parameter varies
depending on age and gender [2, 3] and
can be assessed in physiological conditions
using simple clinical and radiographic
techniques. In our analysis of the different
orthopedic literature sources, we have
detected several international papers
studying the angle of the elbow. However,
1Me Linh General Hospital, Ha Noi
2Hanoi Medical University
Corresponding author: Do Viet Tuyen (doviettuyenvn@gmail.com)
Date received:21/5/2021
Date accepted: 10/6/2021
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
SUBJECTS AND METHODS
goniometer was placed with its hinge in
the center of the cubital crease (midway
between the medial and lateral humeral
condyles). The tips of the two axes of its
arms were directed one toward the lateral
edge of the acromion (easily palpable in
children) and the other toward the midpoint
of the radial and ulnar styloid. This angle
corresponded to the acute angle between
the axis of the arm and the axis of the
fully supinated and extended forearm
held neutral at the elbow (figure 1). An
anteroposterior radiograph of the elbow
was taken in 180 degrees extension with
full supination, ideally extending from the
upper humerus to the wrist. The humeral -
elbow - wrist angle was measured by the
acute angle between 2 axes of the arm
and forearm (figure 2). All the clinical and
radiographic measurements were obtained
by two different examiners in orthopedic
specialty.
1. Subjects
The study included 300 volunteers
(600 elbows) studying at Hoang Kim
preschool, primary and secondary school,
Me Linh district, Ha Noi city.
* Location of study: The study was
carried out at the clinic of Me Linh General
Hospital, Me Linh District, Hanoi City.
* Exclusion criteria: Fractures, sequela
of traumatic injuries, presence of congenital
deformity of the upper limb, inflammatory
diseases, and ligamentous laxity.
2. Methods
We conducted a clinical examination
and took some X-rays of the elbow joint
on both sides in 300 volunteers.
The elbow was in full extension and
supination, the forearm in full supination,
and the wrist at neutral. An orthopedic
A
B
Figure 1: The measurement of the clinical (A) and of the radiographic (B)
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
* Data analysis:
The mean values were then considered for the performance of the necessary
analyses. We used SPSS software to analyze data. The student t-test, Wilcoxon test,
and Mann - Whitney test were used to statistically analyze the mean value.
RESULTS
1. Age and gender
Our study included 300 children aged 6 to 15 years with 144 males (48%) and 156
females (52%).
Table 1: The number of volunteers in each age group following by gender
Gender
Male
Female
Total
Age group
6
7
12
19
17
12
12
17
14
15
14
12
144
48
18
11
13
18
18
13
16
15
16
18
156
52
30
30
30
30
30
30
30
30
30
30
300
8
9
10
11
12
13
14
15
Total
%
In our study, females had an average clinical elbow carrying angel of 9.42 1.23 degrees,
while males had an average clinical elbow carrying angle of 9.29 1.33 degrees.
2. The value of clinical carrying angle
Table 2: The mean value of clinical carrying angle in each group (n = 300).
The mean value of The mean value of
carrying angle in male carrying angle in female
The mean value of
carrying angle
Age groups
p
6
7.48 0.62
(7.00 - 9.00)
Median: 7.25
7.92 0.64
(7.00 - 9.00)
Median: 8.0
7.74 0.66
(7.00 - 9.00)
Median: 7,50
< 0.05
7
8
8.18 0.55
(7.5 - 9.0)
8.07 0.39
(7.5 - 9.0)
8.14 0.50
(7.5 - 9.0)
< 0.05
< 0.05
Median: 8,00
Median: 8.0
Median: 8.00
8.11 0.46
(7.1 - 9.0)
8.32 0.44
(7.6 - 9.1)
8.20 0.46
(7.1 - 9.1)
Median: 8.1
Median: 8.25
Median: 8.15
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
9
8.95 0.53
(8.2 - 9.7)
8.84 0.39
(8.2 - 9.5)
8.89 0.45
(8.2 - 9.7)
< 0.05
< 0.05
< 0.05
< 0.05
< 0.05
< 0.05
< 0.05
< 0.05
Median: 8.95
Median: 8.80
Median: 8.80
10
11
12
13
14
15
9.05 0.68
(7.6 - 10.3)
Median: 9.00
9.14 0.64
(7.5 - 9.8)
9.11 0.65
(7.5 - 10.3)
Median: 9.40
Median: 9.35
9.18 0.65
(8.0 - 10.5)
Median: 9.20
9.45 0.71
(8.00 - 10.5)
Median: 9.5
9.30 0.68
(8.0 - 10.5)
Median: 9.50
9.81 0.74
(8.2 - 11.2)
9.84 0.79
(8.2 - 11.0)
Median: 10.0
9.83 0.76
(8.2 - 11.2)
Median: 10.0
Median: 10.00
10.51 0.92
(8.2 - 12.0)
10.02 0.75
(8.30 - 11.0)
Median: 10.0
10.27 0.87
(8.2 - 12)
Median: 10.6
Median: 10.50
10.88 0.65
(9.8 - 12.5)
10.92 0.74
(10.0 - 11.8)
Median: 11.00
10.90 0.54
(9.8 - 12.5)
Median: 11.00
Median: 11.00
11.25 0.50
(10.4 - 12.2)
Median: 11.3
11.15 0.47
(10,3 - 12,1)
Median: 11.2
11.19 0.48
(10,3 - 12,2)
Median: 11.2
9.29 1.33
(7.0 - 12.5)
Median: 9.10
9.42 1.23
(7.0 - 12.1)
Median: 9.30
9.35 1.28
(7.0 - 13.2)
Median: 9.20
The mean
value
3. The value of carrying angle on radiographic
Table 3: The mean value of carrying angle on anterior - posterior radiographic in
each group (n = 300).
The mean value of The mean value of
carrying angle in male carrying angle in female
The mean value
of carrying angle
Age groups
p
7.58 0.62
(7.0 - 9.2)
7.89 0.64
(7.0 - 9.2)
7.77 0.65
(7.0 - 9.2)
6
< 0.05
Median: 7.45
Median: 8.00
Median: 7.70
8.21 0.60
(7.5 - 9.4)
8.15 0.43
(7.4 - 8.9)
8.19 0.54
(7.4 - 9.4)
7
8
9
< 0.05
< 0.05
< 0.05
Median: 8.00
Median: 8.10
Median: 8.00
8.24 0.57
(7.1 - 9.5)
8.35 0.43
(7.7 - 9.4)
8.30 0.52
(7.1 - 9.5)
Median: 8.10
Median: 8.30
Median: 8.20
9.16 0.60
(8.2 - 10.4)
Median: 9.20
8.98 0.61
(8.1 - 10.4)
Median: 8.80
9.06 0.61
(8.1 - 10.4)
Median: 9.05
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
9.30 0.88
(7.6 - 11.2)
Median: 9.30
9.23 0.82
(7.4 - 11.2)
Median: 9.40
9.11 0.65
(7.5 - 10.3)
Median: 9.20
10
11
12
13
14
15
< 0.05
< 0.05
< 0.05
< 0.05
< 0.05
< 0.05
< 0.05
9.36 0.84
(8.0 - 11.3)
Median: 9.45
9.52 0.77
(7.9 - 10.8)
Median: 9.60
9.43 0.81
(7.9 - 11.3)
Median: 9.50
9.91 0.76
(8.2 - 11.5)
10.14 1.15
(8.2 - 12,2)
10.03 0.99
(8.2 - 12,2)
Median: 10.00
Median: 10.10
Median: 10.0
10.62 1.12
(8.2 - 12.5)
10.29 1.15
(8.3 - 12,2)
10.46 1.13
(8.2 - 12.5)
Median: 10.50
Median: 10.00
Median: 10.50
10.91 0.80
(9.8 - 13.2)
11.22 0.68
(10.0 - 12.5)
Median: 11.00
11.07 0.74
(9.8 - 13.2)
Median: 10.90
Median: 11.00
11.39 0.79
(10.4 - 13.1)
Median: 11.20
11.41 0.83
(10.3 - 13.2)
Median: 11.2
11.40 0.81
(10.3 - 13.2)
Median: 11.2
9.41 1.39
(7.0 - 13.2)
Median: 9.40
9.58 1.42
(7.0 - 13.2)
Median: 9.40
9.50 1.41
(7.0 - 13.2)
Median: 9.40
The mean
value
Tables 2 and 3 presented the results of
the minimum, maximum and mean values
of the elbow carrying angle according to
the age brackets with an interval of 1 year,
between 6 years and 15 years according
to gender. The difference was not statistically
significant between the clinical carrying
angle on two sides in each gender of the
same age.
DISCUSSION
In assessing traumatic elbow injuries in
childhood and adolescence and other
elbow disorders that involve reconstruction
or arthroplasty, measuring the carrying
angle of the elbow and its variations is
vital [4, 5].
We observed mean values for the
elbow carrying angle of 9.350 1.28, with
9.290 1.33 in males and 9.420 1.23 in
females. It is showed in the literature that
this angle increases gradually until it reaches
its maximum value in puberty, an allegedly
sex-related fact according to some authors
that is higher in women [1, 6, 7]. According
to Terra et al. (2011), the average value
The difference was also not statistically
significant between the X-ray carrying
angle on two sides in each gender of the
same age. There was a gradual increase
in the carrying angle from 6 to 15 years.
We did not observe a statistically significant
difference between the clinical and
radiographic measurements (with p > 0.05,
Wilcoxon test or Paired - samples T-test).
of carrying angle was 12.780
5.35 for
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
the females and 11.200
4.45 for the clinical and radiographic measurements.
males [8]. Our results are also similar to Studying the elbow carrying angle in
those authors [8].
children aged 6 to 15 years is very useful
in the clinic. It helps the surgeons to treat
and follow the treatment results with
cubitus varus deformity in children.
Some researchers concluded that the
elbow carrying angle on the dominant
side was higher [7, 8], while in our
analysis we did not find such a similarity.
Statistically, there was no difference
between the right and the left.
REFERENCES
1. Balasubramanian P, Madhuri V, Muliyil J.
Carrying angle in children: A normative study.
J Pediatr Orthop B 2006; 15(1):37-40.
The elbow carrying angle does not
seem to be specifically related to ulna or
humerus height, weight, or length [1].
However, we found some authors who
believe this variable has a relation with
the stature of individuals, suggesting that
the angle of the elbow in shorter people is
higher. By the research by Golden et al.
(2007) [6], we believe that maximum
elbow extension could lead to an increase
in the elbow carrying angle. It was
affected by ligamentous laxity.
2. Beals RK. The normal carrying angle of
the elbow. A radiographic study of 422 patients.
Clin Orthop Relat Res 1976; (119):194-196.
3. Zampagni ML, Casino D, Zaffagnini S et
al. Estimating the elbow carrying angle with
an electrogoniometer: Acquisition of data and
reliability of measurements. Orthopedics 2008;
31(4):370.
4. Zampagni ML, Casino D, Martelli S et al.
A protocol for clinical evaluation of the
carrying angle of the elbow by anatomic
landmarks. J Shoulder Elbow Surg, 2008;
17(1):106-112.
Studying the elbow carrying angle in
children aged 6 to 15 years is very useful
in determining the degree of elbow
deformity after a fracture in the distal of
the humerus. Based on the normal
carrying angle on the normal side, the
surgeons can determine the degree of
angle when cutting bones to correct the
distal of the humerus for treatment of
cubitus varus deformity in children, and they
also could follow the treatment results easily.
6. Golden DW, Jhee JT, Gilpin SP et al.
Elbow range of motion and clinical carrying
angle in a healthy pediatric population. J Pediatr
Orthop B 2007; 16(2):144-149.
7. Tükenmez M, Demirel H, Perçin S et al.
Measurement of the carrying angle of the
elbow in 2,000 children at ages six and
fourteen years. Acta Orthop Traumatol Turc
2004; 38(4):274-276.
CONCLUSION
8. Terra BB, Silva BCM, Carvalho HBF et al.
Evolution of the carrying angle of the elbow:
A clinical and radiographic study. Acta Ortop
Bras 2011; 19(2):79.
The elbow carrying angle increases
progressively from 6 until 16 years. There
was no statistical difference between the
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