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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 71-74

Anthropometric characterisation of elbow angles and lines among Indian children


1 Department of Orthopedics, Dr. RPGMC, Tanda, Kangra, Himachal Pradesh, India
2 Department of Community Medicine, Dr. RPGMC, Tanda, Kangra, Himachal Pradesh, India
3 Department of Radiodiagnosis, Dr. RPGMC, Tanda, Kangra, Himachal Pradesh, India

Date of Web Publication28-Apr-2017

Correspondence Address:
Sunil Kumar Raina
Department of Community Medicine, Dr. RPGMC, Tanda, Kangra, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AIHB.AIHB_2_17

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  Abstract 

Background: For understanding injuries in paediatric elbow and checking the degree of reduction after manipulation, various radiological criteria using anthropometric parameters are used. Since anthropometric parameters of Caucasians are different from European and Mongoloids, their parameters cannot be applied on our population. Hence, there is a need to characterise anthropometric parameters of elbow among children in the Indian population. Materials and Methods: The study population comprised all cases of injury to the elbow joint between 3 and 13 years of age reporting to the Department of Orthopaedics during the study. The X-rays films were preserved, and the angles and lines (as anthropometric parameters) were drawn on the radiographs. Results: Mean ± (standard deviation [SD]) for Baumann angle in children included in this study was 75° ± 4.70°. Mean ± (SD) of Baumann angle in males was 76° ± 4.44° and females was 74° ± 5.37°. Mean ± (SD) for lateral capitellohumeral angle in children from 3 to 13 years of age was 49 ± 5.75. Conclusions: As the values of normal side have been found to affect the functional and cosmetic outcome of the affected extremity, slight changes in values of our population in comparison to that of the Western population can significantly affect the outcome.

Keywords: Angles, anthropometric, characterisation, elbow, lines


How to cite this article:
Awasthi B, Raina SK, Chauhan N, Sehgal M, Sharma V, Thakur L. Anthropometric characterisation of elbow angles and lines among Indian children. Adv Hum Biol 2017;7:71-4

How to cite this URL:
Awasthi B, Raina SK, Chauhan N, Sehgal M, Sharma V, Thakur L. Anthropometric characterisation of elbow angles and lines among Indian children. Adv Hum Biol [serial online] 2017 [cited 2019 Jul 23];7:71-4. Available from: http://www.aihbonline.com/text.asp?2017/7/2/71/205389


  Introduction Top


Trauma to the child's elbow may result in bony, cartilaginous or soft tissue injury. Just as adults, children instinctively protect their central core from a fall with their arms outstretched hence tend to break their bone in similar form. Epidemiological studies have shown that paediatric elbow fractures have both a higher incidence and greater variability in fracture patterns as compared with adults.[1]

Overall, 65%–75% of all fractures in children occur in the upper extremity [2] with supracondylar fractures accounting for 60% among them.[3] This area of the bone is relatively weak due to the metaphyseal remodelling that takes place during the first 10 years of development; and therefore, the incidence of this injury peaks at 5–8 years of age.[4] The number of elbow injuries continues to rise following increased levels of participation of children in recreational and competitive sports.[5]

To understand injuries in paediatric elbow and checking the degree of reduction after manipulation, various radiological criteria are used. These are Baumann's angle in anteroposterior view, humerocondylar angle in lateral view, anterior humeral line, and radiocapitellar line. Literature search on information regarding angles and lines around elbow, on PubMed, reveals that the studies are limited to the European and some Mongoloid populations. Very few studies are available which tell the normal limits of these angles and lines in the Asian population. Since anthropometric parameters of Caucasians are different from European and Mongoloids, their parameters cannot be applied on our population.[6] Hence, the study was planned to arrive at these angles and lines in our population.

Further extensive PubMed search shows only one study on the Asian population conducted in Hong Kong [7] characterising the Baumann's angle. However, not a single study characterising anterior humeral line, radiocapitellar line, radiocapitellar bisection and lateral humerocapitellar angle has been performed on the Asian population. Herein lies the importance of our study which delineates these angles and lines in an Indian population from a rural background in Northwest India.


  Materials and Methods Top


The study was conducted on all consenting patients aged 3–13 years presenting to the Department of Orthopaedics of Medical College in Northwest India, from January 1, 2013, to December 31, 2013, with injuries around the elbow joint. Patients with injury to bilateral elbow (old or new) and with congenital deformities around bilateral elbow joint were excluded from the study. Further children <3 years of age and above 13 years of age were also excluded from the study.

The study was approved by the Institution Ethics Committee. An enquiry was made into the details of each study participants. The details of the study participants were recorded in a case recording format. The case recording format included details on age, sex, side, Baumann's angle, lateral capitellohumeral angle, anterior humeral line and radiocapitellar line of the patient.

After the details were collected, the study participants were sent for radiological examination using X-rays as the investigation modality. The X-rays films thus collected for each study participants were preserved. Angles and lines were drawn on each preserved X-ray film independent of the radiologist. The films and the angles and lines were then reviewed with a radiologist on weekly basis. After the review, a consensus was obtained on the measurement of the angles and lines. The consensus was taken as the final measurement.

Parental permission was sought before including the child up to 7 years of age in the study after ensuring the following things:

  • The process was conducted in a manner and location that ensures participant's privacy
  • Giving adequate information about the study in a language understandable to the participant
  • Providing adequate opportunity for the participant to consider all options
  • Responding to the participant's questions
  • Ensuring the participant has understood the information provided
  • Obtaining the participant's voluntary agreement to participate and
  • Continuing to provide information as the participant or research requires.


In children above 7 years, assent from children in addition to parental permission after fulfilling the above criteria was obtained.

Statistical analysis

The angles were analysed using mean and standard deviation (SD) and expressed with confidence interval. The lines were expressed as percentage using already defined criteria.


  Results Top


[Table 1] shows the mean ± (SD) for Baumann angle in children in the study is 75° ± 4.70°. Mean ± (SD) of Baumann angle in males is 76° ± 4.44° and females is 74° ± 5.37°. Ninety (70%) children (male n = 67, 76%; females n = 23, 60%) have Baumann angle in the range of 71°–80°. [Table 2] shows mean ± (SD) for lateral capitellohumeral angle in children from 3 to 13 years of age is 49 ± 5.75. Mean ± (SD) value in males is 48° ± 5.50° and females is 50° ± 6.27°. Seventy-three (58.54%) children (male n = 57, 64.7%; females n = 16, 42%) have lateral capitellohumeral angle in the range of 41°–50°. [Table 3] shows in majority of the cases anterior humeral line passed through the middle 1/3rd of the capitellum (108 cases, 86.4%) 75 (85.2%) male children and 33 (89.18%) female children have anterior humeral line passing through middle 1/3rd of capitellum. As seen in the above [Table 4], radiocapitellar bissection was present in 85.6% of cases. In males, 87.5% cases have radiocapitellar bissection whereas in females bissection was present in 81%.
Table 1: Baumann angle in Indian children

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Table 2: Lateral capitellohumeral angle in Indian children

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Table 3: Anterior humeral line intersection among Indian children

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Table 4: Radiocapitellar bisection among Indian children

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  Discussion Top


Extensive PubMed search has revealed very little literature on the elbow angles and lines in paediatric population in developing countries of Africa and Asia, including India. Till date, no such study has been found on PubMed search regarding delineating the normal values of elbow angles and lines in paediatric population of India.

It is very important to understand the normal values, ranges, relationship of these angles and lines for management of fractures because of the impact they have on our acceptability criteria. It also helps us to reduce post-reduction deformities. Values obtained from Western literature cannot be applied on our population due to various anthropometric differences.

Our study of 125 cases aims to provide normal values of Baumann angle, lateral capitellohumeral angle, radiocapitellar line, anterior humeral line and radiocapitellar bisection in our paediatric population from 3 to 13 years of age. Studies conducted across populations have given different values for the Baumann angle. In our study of 125 children belonging to age group 3–13 years of age which as far as we are aware of the largest study done for the value of Baumann angle, the mean value in males was 76° with SD of 4.44 and in females were 74° with SD of 5.37. The age group in our study was 3–13 years of age and average mean value for Baumann angle was 75 with SD of 4.71. A study conducted in Hong Kong, China, on 105 radiographs concluded the mean Baumann angle in boys was 70.1° with SD of 5.8 and in females to be 69.9 with SD of 5.7°.[7] Williamson et al.[8] in a study done in Melbourne, Australia, proposed a mean value of 70° with an SD of 4°. According to Worlock,[9] its value is 75° in his study of 29 children in England. These two studies did not differentiate the values among males and females.

The data analysis reveals an interesting finding that the mean value of Baumann angle in Indian children is comparable to the Western population but higher than the Chinese population. The difference between male and female Baumann angle is not statistically significant. Indian children tend to have a wider distribution of Baumann angle although the average values are close to that of Western and Chinese counterparts. As per our extensive literature search till date, only three studies are available on lateral capitellohumeral angle. The studies done in earlier half of the 20th century in various parts of Germany dealing with quantitative anatomy of the elbow in the sagittal plane, measured the lateral capitellohumeral angle between 30° and 40°.[10],[11] In our study, mean lateral capitellohumeral angle in children from 3 to 13 years of age is 49° ± 5.75°. Mean value for lateral capitellohumeral angle in males is 48° ± 5.50° and females is 50° ± 6.27°. The difference in males and females is statistically insignificant. A study done by Shank et al.[12] on 71 radiographs of children in Seattle shows that in normal elbows, the mean lateral capitellohumeral angle is 51° ± 6° and does not vary with age, side or sex. Simanovsky et al.[13] found that mean value for lateral capitellohumeral angle for all ages was 41.6° (30°–70°) among Israeli children. We found a wide variation of lateral capitellohumeral angle values from 30° to 60°; however, the absolute number of such patients was relatively small. Our results are intermediate of the results of the two Western studies placing lateral capitellohumeral angle between 40° and 55°. In a study done on 120 radiographs by Herman et al.[14] at the Cincinnati children hospital, the anterior humeral line passed through the anterior third of the capitellum in 31% of the elbows, the middle third in 52% and the posterior third in 18%. In the present study, the anterior humeral line was evaluated for reliability in the largest series of paediatric elbows yet reported. We observed that anterior humeral line passed through middle 1/3rd of capitellum in 108 (86.4%) of the cases.

In 5.6% of the cases, it passed through the anterior 1/3rd and 8% of the cases, it passed through the posterior 1/3rd. In older children (4–9 years), the anterior humeral line passed through the middle third in 62% of the elbows in a study done by Herman et al.[14]

One reason for this discrepancy is the age group used in the Western study which was 4 months to 9 years, whereas in our study, age group is 3–13 years. We have used this age group as ossification centre for the capitellum appears on radiograph after 2.5 years giving a better and accurate analysis of radiographs. The results of our study further supports that anterior humeral line can be used as an important marker to quantify anterior-posterior displacement of the distal part of the humerus after a supracondylar elbow fracture and the adequacy of fracture reduction after treatment in the Indian population. Our study aimed at calculating the radiocapitellar intersection and bisection on lateral radiographs of elbow using the line passing through radial neck as reference. In our study, radiocapitellar intersection occurred in 100% of the cases. Radiocapitellar bisection was seen in 85.9% of the X-rays. A study ahead of publication by Ramirez et al.[15] which according to them is the largest study done on 116 radiographs found radiocapitellar intersection to be 98.2% and radiocapitellar bisection to be 77.8% on the lateral radiogarphs. In a study done by Samuel et al. in 2011 in Seattle children's hospital, radiocapitellar instersection was 95%, and radiocapitellar bissection was present in 63% cases. They suggested that subtle malalignment of the radiocapitellar joint may not be best assessed by the radiocapitellar line and when such malalignment is suspected investigations such as ultrasonograhy and magnetic resonance imaging should be done. However, our study and study done by Ramirez et al.[15] refutes the claim of Samuel et al. and advocates radiocapitellar intersection to be a strong predictor for detecting subtle malalignment in Monteggia fracture dislocations.

The study outlines the role of radiocapitellar intersection in primary care settings where facilities of magnetic resonance imaging and ultrasonography are not readily available.


  Conclusions Top


This study defines the normal values of Baumann angle and lateral capitellar humeral angle in children. As the values of normal side have found to affect the functional and cosmetic outcome of the affected extremity, slight changes in values of our population from that of the Western population can significantly affect the outcome. In addition, our finding that radiocapitellar intersection is present in 100% cases further strengthen the importance of this line and its routine use to detect any subtle dislocations of radial head, especially in fractures of the upper 1/3rd of ulna. Anterior humeral line also emerges as a strong indicator to quantify anterior-posterior displacement of the distal part of the humerus after a supracondylar elbow fracture and the adequacy of fracture reduction after treatment.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Woods GW, Tullos HS. Elbow instability and medial epicondyle fractures. Am J Sports Med 1977;5:23-30.  Back to cited text no. 1
    
2.
Rogers LF. Radiology of Skeletal Trauma. 2nd ed. New York: Churchill Livingstone; 1992. p. 749-836.  Back to cited text no. 2
    
3.
Crombie A, Duncan R. Closed reduction and percutaneous fixation of displaced paediatric supracondylar fractures of the elbow. Curr Orthop 2004;18:147-53.  Back to cited text no. 3
    
4.
Steenbrugge FM. Guidelines and pitfalls in the management of supracondylar humerus fractures in children. Curr Orthop 2001;15:214-9.  Back to cited text no. 4
    
5.
DeLee JC, Drez D, Miller MD. DeLee and Drez's Orthopaedic Sports Medicine. 3rd ed. Amsterdam, Netherlands: Elsevier Publishers; 2009.  Back to cited text no. 5
    
6.
Zhuang Z, Landsittel D, Benson S, Roberge R, Shaffer R. Facial anthropometric differences among gender, ethnicity, and age groups. Ann Occup Hyg 2010;54:391-402.  Back to cited text no. 6
    
7.
Yeung SH, Lam CY, Ho HM, Ko PP, Ng JK, Lam JJ. Characterstics of Baumann's angle in Hong Kong Chinese children. Hong Kong Med J 1996;2:363-5.  Back to cited text no. 7
    
8.
Williamson DM, Coates CJ, Miller RK, Cole WG. Normal characteristics of the Baumann (humerocapitellar) angle: An aid in assessment of supracondylar fractures. J Pediatr Orthop 1992;12:636-9.  Back to cited text no. 8
    
9.
Worlock P. Supracondylar fractures of the humerus. Assessment of cubitus varus by the Baumann angle. J Bone Joint Surg Br 1986;68:755-7.  Back to cited text no. 9
    
10.
Von Katzmann H. On the treatment of supracondylar upper arm fractures in children. Zentralbl Chir 1965;40:2089-97.  Back to cited text no. 10
    
11.
Von Ekesparre F. Treatment of supracondylar humerus fracture in childhood. Dtsch Med J 1958;9:168-73.  Back to cited text no. 11
    
12.
Shank CF, Wiater BP, Pace JL, Jinguji TM, Schmale GA, Bittner RC, et al. The lateral capitellohumeral angle in normal children: Mean, variation, and reliability in comparison to Baumann's angle. J Pediatr Orthop 2011;31:266-71.  Back to cited text no. 12
    
13.
Simanovsky N, Lamdan R, Mosheiff R, Simanovsky N. Underreduced supracondylar fracture of the humerus in children: Clinical significance at skeletal maturity. J Pediatr Orthop 2007;27:733-8.  Back to cited text no. 13
    
14.
Herman MJ, Boardman MJ, Hoover JR, Chafetz RS. Relationship of the anterior humeral line to the capitellar ossific nucleus: Variability with age. J Bone Joint Surg Am 2009;91:2188-93.  Back to cited text no. 14
    
15.
Ramirez RN, Ryan DD, Williams J, Wren TA, Ibrahim D, Weiss JM, et al. A line drawn along the radial shaft misses the capitellum in 16% of radiographs of normal elbows. J Pediatr Orthop 2014;34:763-7.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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