Journal OF MILITARY PHARMACO MEDICINE N05 2021 186 RESULTS OF ASSESSMENT OF THE CARRYING ANGLE OF THE ELBOW A CLINICAL AND RADIOGRAPHIC STUDY Do Viet Tuyen1, Dao Xuan Tich2 SUMMARY Objectives To asses[.]
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 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 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 until 16 years There was no statistical difference between the clinical and radiographic measurements Studying the elbow carrying angle in children aged to 15 years is very useful in the treatment of cubitus varus deformity * Keywords: Elbow carrying angle; Cubitus varus deformity INTRODUCTION 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, 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 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 Me Linh General Hospital, Ha Noi Hanoi Medical University Corresponding author: Do Viet Tuyen (doviettuyenvn@gmail.com) Date received:21/5/2021 Date accepted: 10/6/2021 186 Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021 SUBJECTS AND METHODS 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 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 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 axes of the arm and forearm (figure 2) All the clinical and radiographic measurements were obtained by two different examiners in orthopedic specialty B Figure 1: The measurement of the clinical (A) and of the radiographic (B) 187 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 Age and gender Our study included 300 children aged 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 12 18 30 19 11 30 17 13 30 Age group 12 18 30 10 12 18 30 11 17 13 30 12 14 16 30 13 15 15 30 14 14 16 30 15 12 18 30 Total 144 156 300 % 48 52 In our study, females had an average clinical elbow carrying angle of 9.42 ± 1.23 degrees, while males had an average clinical elbow carrying angle of 9.29 ± 1.33 degrees The value of clinical carrying angle Table 2: The mean value of clinical carrying angle in each group (n = 300) Age groups The mean value of carrying angle in male The mean value of carrying angle in female 7.48 ± 0.62 7.92 ± 0.64 188 p The mean value of carrying angle 7.74 ± 0.66 < 0.05 (7.00 - 9.00) (7.00 - 9.00) Median: 7.25 Median: 8.0 Median: 7,50 8.18 ± 0.55 8.07 ± 0.39 8.14 ± 0.50 (7.5 - 9.0) (7.5 - 9.0) Median: 8,00 Median: 8.0 8.11 ± 0.46 8.32 ± 0.44 (7.1 - 9.0) (7.6 - 9.1) Median: 8.1 Median: 8.25 < 0.05 (7.00 - 9.00) (7.5 - 9.0) Median: 8.00 8.20 ± 0.46 < 0.05 (7.1 - 9.1) Median: 8.15 Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021 10 11 12 13 14 15 The mean value 8.95 ± 0.53 (8.2 - 9.7) Median: 8.95 8.84 ± 0.39 (8.2 - 9.5) Median: 8.80 < 0.05 8.89 ± 0.45 (8.2 - 9.7) Median: 8.80 9.05 ± 0.68 (7.6 - 10.3) Median: 9.00 9.14 ± 0.64 (7.5 - 9.8) Median: 9.35 < 0.05 9.11 ± 0.65 (7.5 - 10.3) Median: 9.40 9.18 ± 0.65 (8.0 - 10.5) Median: 9.20 9.45 ± 0.71 (8.00 - 10.5) Median: 9.5 < 0.05 9.30 ± 0.68 (8.0 - 10.5) Median: 9.50 9.81 ± 0.74 (8.2 - 11.2) Median: 10.00 9.84 ± 0.79 (8.2 - 11.0) Median: 10.0 < 0.05 9.83 ± 0.76 (8.2 - 11.2) Median: 10.0 10.51 ± 0.92 (8.2 - 12.0) Median: 10.6 10.02 ± 0.75 (8.30 - 11.0) Median: 10.0 < 0.05 10.27 ± 0.87 (8.2 - 12) Median: 10.50 10.88 ± 0.65 (9.8 - 12.5) Median: 11.00 10.92 ± 0.74 (10.0 - 11.8) Median: 11.00 < 0.05 10.90 ± 0.54 (9.8 - 12.5) 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 < 0.05 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 < 0.05 9.35 ± 1.28 (7.0 - 13.2) Median: 9.20 The value of carrying angle on radiographic Table 3: The mean value of carrying angle on anterior - posterior radiographic in each group (n = 300) Age groups The mean value of carrying angle in male The mean value of carrying angle in female p The mean value of carrying angle 7.58 ± 0.62 (7.0 - 9.2) Median: 7.45 7.89 ± 0.64 (7.0 - 9.2) Median: 8.00 < 0.05 7.77 ± 0.65 (7.0 - 9.2) Median: 7.70 8.21 ± 0.60 (7.5 - 9.4) Median: 8.00 8.15 ± 0.43 (7.4 - 8.9) Median: 8.10 < 0.05 8.19 ± 0.54 (7.4 - 9.4) Median: 8.00 8.24 ± 0.57 (7.1 - 9.5) Median: 8.10 8.35 ± 0.43 (7.7 - 9.4) Median: 8.30 < 0.05 8.30 ± 0.52 (7.1 - 9.5) 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 < 0.05 9.06 ± 0.61 (8.1 - 10.4) Median: 9.05 189 Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021 10 9.30 ± 0.88 (7.6 - 11.2) Median: 9.30 9.23 ± 0.82 (7.4 - 11.2) Median: 9.40 < 0.05 9.11 ± 0.65 (7.5 - 10.3) Median: 9.20 11 9.36 ± 0.84 (8.0 - 11.3) Median: 9.45 9.52 ± 0.77 (7.9 - 10.8) Median: 9.60 < 0.05 9.43 ± 0.81 (7.9 - 11.3) Median: 9.50 12 9.91 ± 0.76 (8.2 - 11.5) Median: 10.00 10.14 ± 1.15 (8.2 - 12,2) Median: 10.10 < 0.05 10.03 ± 0.99 (8.2 - 12,2) Median: 10.0 13 10.62 ± 1.12 (8.2 - 12.5) Median: 10.50 10.29 ± 1.15 (8.3 - 12,2) Median: 10.00 < 0.05 10.46 ± 1.13 (8.2 - 12.5) Median: 10.50 14 10.91 ± 0.80 (9.8 - 13.2) Median: 10.90 11.22 ± 0.68 (10.0 - 12.5) Median: 11.00 < 0.05 11.07 ± 0.74 (9.8 - 13.2) Median: 11.00 15 11.39 ± 0.79 (10.4 - 13.1) Median: 11.20 11.41 ± 0.83 (10.3 - 13.2) Median: 11.2 < 0.05 11.40 ± 0.81 (10.3 - 13.2) Median: 11.2 The mean value 9.41 ± 1.39 (7.0 - 13.2) Median: 9.40 9.58 ± 1.42 (7.0 - 13.2) Median: 9.40 < 0.05 9.50 ± 1.41 (7.0 - 13.2) Median: 9.40 Tables and presented the results of the minimum, maximum and mean values of the elbow carrying angle according to the age brackets with an interval of year, between 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 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 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) 190 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 of carrying angle was 12.780 ± 5.35 for Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021 the females and 11.200 ± 4.45 for the males [8] Our results are also similar to those authors [8] 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 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 Studying the elbow carrying angle in children aged 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 CONCLUSION The elbow carrying angle increases progressively from until 16 years There was no statistical difference between the clinical and radiographic measurements Studying the elbow carrying angle in children aged 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 REFERENCES Balasubramanian P, Madhuri V, Muliyil J Carrying angle in children: A normative study J Pediatr Orthop B 2006; 15(1):37-40 Beals RK The normal carrying angle of the elbow A radiographic study of 422 patients Clin Orthop Relat Res 1976; (119):194-196 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 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 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 Tỹkenmez M, Demirel H, Perỗin 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 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):79 191 ... clinical elbow carrying angle of 9.42 ± 1.23 degrees, while males had an average clinical elbow carrying angle of 9.29 ± 1.33 degrees The value of clinical carrying angle Table 2: The mean value... 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... mean value of carrying angle on anterior - posterior radiographic in each group (n = 300) Age groups The mean value of carrying angle in male The mean value of carrying angle in female p The mean