Correlation Between Bauman's and Carrying Angle in Children with Supracondylar Fracture of Humerus

Abstract

Supracondylar fractures are the result of a fall on outstretched hand in more than 70% of cases, and more common in the non-dominant arm. Bauman's angle is used to determine the degree of displacement and angulation, and the quality of fracture reduction. Carrying angle is the clinical parameter of varus-valgus angulation with elbow fully extended and forearm completely supinated. Patients and methods: The study was a retrospective-prospective and there were analyzed children under 14 years of age with supracondylar humerus fracture. They were analyzed by X-ray anteroposterior view of injured elbow, made before and after the surgery, with measuring Bauman's angle. Clinical examination was performed after completing physical therapy, when was measured carrying angle of the injured and healthy elbow using a goniometer. Results and discussion: The results showed that there is a negative correlation Bauman and carrying angle of injured elbow (r=-0.543, p 0.0001). Analyzing Bauman's angle deviation from value of 75 ° and the loss of carrying angle there is noticed significant positive correlation between the Bauman angle deviation and loss of carrying angle. Bauman's angle correlates well with the carrying angle and can be used as an indicator of the potential cosmetic complications. Conclusion: Carrying angle of uninjured elbow measured when reviewing a child who has suffered supracondylar fracture, can serve as a useful parameter in the assessment of real Bauman's angle, thereby the adequacy of fracture reduction on the injured arm.

Correlation Between Baumans and Carrying Angle in Children with Supracondylar Fracture of Humerus

DOI: 10.5455/medarh.2013.67.195-197 Med Arh. 2013 Jun; 67(3): 195-197

Received: January 21th 2013 | Accepted: March 15th 2013

CONFLICT OF INTEREST: NONE DECLARED

ORIGINAL PAPER

Correlation Between Baumans and Carrying Angle in Children with Supracondylar Fracture of Humerus

Nedim Smajic1, Jasmina Smajic2, Sahmir Sadic1, Mahir Jasarevic1, Jasmina Ahmetovic-Djug2, Renata Hodzic3

University Clinical Centre, Orthopaedic and Traumatology Clinic, Tuzla, Bosnia and Herzegovina1

University Clinical Centre, Anesthesiology and Reanimatology Clinic, Tuzla, Bosnia and Herzegovina2

University Clinical Centre, Neurology Clinic, Tuzla, Bosnia and Herzegovina3

Supracondylar fractures are the result of a fall on outstretched hand in more than 70% of cases, and more common in the non-dominant arm. Baumans angle is used to determine the degree of displacement and angulation, and the quality of fracture reduction. Carrying

angle is the clinical parameter of varus-valgus angulation with elbow fully extended and forearm completely supinated. Patients and methods: The study was a retrospective-prospective and there were analyzed children under 14 years of age with supracondylar humerus fracture. They were analyzed by X-ray anteroposterior view of injured elbow, made

before and after the surgery, with measuring Baumans angle. Clinical examination was performed after completing physical therapy, when was measured carrying angle of the injured and healthy elbow using a goniometer.

Results and discussion: The results showed that there is a negative correlation Bauman and carrying angle of injured elbow (r=-0.543, p <0.0001). Analyzing Baumans angle deviation from value of 75 and the loss of carrying angle there is noticed signicant positive correlation between the Bauman angle deviation and loss of carrying angle. Baumans angle correlates well with the carrying angle and can be used as an indicator of the potential cosmetic complications. Conclusion: Carrying angle of uninjured elbow measured when reviewing a child who has suered supracondylar fracture, can serve as a useful parameter in the assessment of real Baumans angle, thereby the adequacy of fracture reduction on the injured arm. Keywords: supracondylar fracture, humerus, Baumans angle, carrying angle

Correspondent author: Mr. sci. Nedim Smajic, MD. Phone: [phone]. E-mail:[email protected],

1. INTRODUCTION

Supracondylar fractures are the result of a fall on outstretched hand in more than 70% of cases, and more common on the non dominant arm. Children tend to protect themselves with extending the arm during the fall, thereby explaining the high incidence of fracture of the upper extremity. Supracondylar fractures are the most common cause of hospitalization of children with elbow injury (1, 2). They occur in two basic types: extension, more common type (98%), and less

common exion type (2%). Extension type of supracondylar fracture usually occurs in the fall on the outstretched hand with elbow in hyper extension, and exion type as a result of the direct eect of force on the back of the elbow. Diagnosis of supracondylar fracture is based on the clinical signs and radiological examinations (3). To determine the degree of displacement and angulation, and the quality of fracture reduction is used Baumans angle (4). Baumans angle is measured after fracture reduction on the anteroposterior X-ray view,

and it is represented by a line that goes along the epiphiseal capitulum and the longitudinal axis of the humerus. Normal value is 75 , while the increase in value by 5 or more indicates varus deformity, a decrease of 5 and more valgus deformity (5, 6). Carrying angle is the clinical indication of varus-valgus angulation of the arm with elbow fully extended and forearm completely supinated. This angle is dened by the section of the line that runs along the middle axis of the arm and the line that runs along the middle axis of forearm. There is no signicant dierence in the carrying angle value in men and women, but there is signicant dierence based on age. At the age of 0-4 years the value is about 15 and 17.8 in adults. Increasing this angle indicates a valgus deformity, and reducing the varus deformity (7).

2. AIM

The aim of this study was to determine the correlation between Baumans angle measured on the anteroposterior X-ray view injured arm after reduction, and carrying angle injured arm after nished treatment.

3. SUBJECTS AND METHODS

The study was a retrospective-prospective and analyzed for children under 14 years of age with supracondylar

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Correlation Between Baumans and Carrying Angle in Children with Supracondylar Fracture of Humerus

FIGURES AND TABLES

Table 1. Bauman's angle values in studied groups

humerus fractures, surgically treated at Orthopedic-Traumatology Clinic of the University Clinical Center Tuzla in the period from January 2005 to September 2010. Including criterion was completely displaced supracondylar fracture of humerus (Gartland type III extension type), while excluding criterion was an open fracture, as well as the existence of another a fracture on the same hand. The proper medical documentation was used: case histories, X-ray images before and after treatment, and ambulatory protocols. Postoperative testing was performed at least three months after surgery. Random selection method selected 60 subjects who were invited and analyzed as follows: The rst group (group 1) were patients who were hospitalized for up to 24 hours of the injury and who were immediately treated surgically without attempting closed fracture reduction and cast immobilization. The second group (group 2) were patients who underwent surgery after 24 hours of injuries; surgical treatment after this period was made because the respondents appeared later, or a failed closed fracture reduction with cast immobilization Anteroposterior X-ray views of injured elbow were analyzed, made

before and after surgery. Preoperative images were used to conrm the diagnosis supracondylar fractures and determine the degree of dislocation. Postoperative recordings were used to assess the quality of the repositioning of the fracture. Baumans angle was measured. Baumans angle was measured on the anteroposterior image, and presented to the lines that go to the longitudinal axis of the humerus capitulum and along the epiphysis. The values

of this angle 75 5 were considered as anatomical reconstruction. After completing the physical therapy clinical examination was performed, which was measured carrying angle of the injured and healthy elbow. Carrying angle was measured using a goniometer, in the full extension of forearm. It is dened by the section of the line that runs along the middle axis of the arm and the line that runs along the middle axis of forearm. Based on data obtained the degree of loss of carrying angle injured compared to

healthy elbow was evaluated. For statistical analysis of data was used statistical software SPSS 12. Statistical analysis of data was performed by descriptive statistics to calculate the mean and standard deviation, and t-test and test to calculate the significance of the established results. Statistical analysis was performed with a condence interval of 95%, a value of p <0.05 was considered signicant.

4. RESULTS

The study involved two groups of 30 patients each. The rst group of patients underwent surgery to 24 after injury (group 1), there were 20 boys and 10 girls, and the second group underwent surgery after 24 h of injury (group 2) and there were 19 boys and 11 girls (p = 0.37) . The average of the rst group was 7.16 2, 46, and another group of subjects 7.23 2.81 years (p = 0.46).

In both groups the largestnumber of respondents belonged to a life sentenced tosix to ten years. Regard toposition of the distal fragment in both groups there is higher number of respondents with posteromedial dislocation of the distal fragment (p = 0.14). In both groups more of respondents had a fracture of the left humerus (p = 0.1), which was mostly non dominant. Measurement of Baumans angle on the anteroposterior view in both groups showed no statistically signicant difference in their values (p = 0.37) (Table 1). In both groups the majority of respondents had a value of Baumans angle 70-80 (Figure 1). Increase of Baumans angle in both studied groups mostly occurs in posteromedial dislo-

cation (dislocations 1), and decrease in the posterolateral dislocation of the distal fragment (dislocations 2) (Figure 2). The mean carrying angle of the injured elbow after completing physical therapy in group 1 was 11.90 7.80 , and in second group 13.37 6.89 (p = 0.21). The

Group 1 Group 2 Mean 75.73333 76.23333 Variance 33.85747 38.73678 Standard deviation 5.818717 6.223888

Table 1. Baumans angle values in studied groups

Group 1 Group 2

Mean 75.73333 76.23333

Variance 33.85747 38.73678

Standard deviation 5.818717 6.223888

Figure1. Baumans angle values

Figure1. Bauman's angle values

Figure 2. Baumans angle and distal fragment dislocation

Figure 2. Bauman's angle and distal fragment dislocation

Figure 3. Loss of caryying angle of injured elbow in studied groups

Figure 2. Bauman's angle and distal fragment dislocation

Figure 3. Loss of caryying angle of injured elbow in studied groups

Figure 3. Loss of caryying angle of injured elbow in studied groups

mean carrying angle of the healthy elbow in the rst group was 14 1.36 , and in the second group 14.43 0.89 (p = 0.07). Loss of carrying angle of the

Figure 4. Correlation in Baumans and carrying angle on injured elbow

Figure 4. Correlation in Bauman's and carrying angle on injured elbow

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Correlation Between Baumans and Carrying Angle in Children with Supracondylar Fracture of Humerus

Figure 5. Correlation between Baumans angle deviation and loss of carrying angle

Figure 5. Correlation between Bauman's angle deviation and loss of carrying angle

injured elbow in the rst group was 4.30 7.66 , and the second group 5 6.11 (p = 0.35) (Figure 3). In both studied groups there was a negative correlation between Baumans and carrying angle of injured elbow (r = -0.543, p <0.0001) (Figure 4). Analyzing deviation of Baumans angle from the value of 75 with the loss of carrying angle a signicant positive correlation between the deviation Baumans angle and loss of carrying angle was noticed (Figure 5).

5. DISCUSSION

Supracondylar fractures of the humerus are the most common type of elbow fracture in children and adolescents and accounts for 16% of all fractures in childhood. In 60% of cases the fracture is on the left, usually the non dominant hand (8). Dislocated supracondylar fractures can lead to serious residual deformity if they are not reduced and stabilized in the optimum position. The goal of treatment is to achieve and maintain the anatomic location of the fractured fragments, which leads to rapid recovery with the return of full and unrestricted function with minimal risk of complications. After making the stabilization the goal is to preserve the position of fractured fragments since the loss of reduction leads to changes of carrying angle and to possible occurrence of cubitus varus. Adequacy of supracondylar fracture reduction is observed on anteroposterior and prole view of elbow. Baumans angle is a good indicator of the adequacy of repositioning. This is based on the assumption that Baumans angle is in constant relation to the carrying angle in dislocated fractures.

Dai conducted a study in 1999 and found a signicant correlation between

Baumans angle that was measured immediately after repositioning and carrying angle that was measured in the postoperative follow-up. He concluded that the measurement of the Baumans angle after the repositioning can be used for estimating of the nal carrying angle, which is important for the prevention of cubitus varus (9). Silva et al. conducted a study in 2010th and they examined the Baumans angle in 35 children with supracondylar fractures. They concluded that the Baumans angle is simple, easily measurable and reliable indicator that can be used to assess the outcome of supracondylar fractures in children (10). Besides Baumans angle which is used to evaluate the adequacy of fracture reduction, measuring of carrying angle is performed, and it is used to evaluate the success of treatment. Changes in carrying angle after supracondylar fractures occur as a result of inadequate anatomical reconstruction due to loss or repositioning, and may also be due to disturbances in the growth of the distal end of the humerus (11, 12). Worlock conducted a study that examined the correlation of Baumans and carrying angle on the uninjured, and the same angles on the injured arm. This study has shown a direct correlation in Baumans and carrying angle. With increase of the Baumans angle there is decrease in the value of carrying angle on the healthy and the injured arm (13). Measurement of Baumans angle after supracondylar fracture reduction is a good indicator of the nal value of carrying angle injured arm, and thus of the potential occurrence the angular deformity.

In our study, in both studied groups, postoperative anteroposterior X-rays of the injured elbow were made and the Baumans angle was measured (). Reciprocal angle (90-) is approximately equal to the carrying angle, which is measured by goniometer. Correlation of reciprocal angle on the anteroposterior image and carrying angle measured with goniometer was used in our study.

After the carrying angle on healthy elbow was measured, Baumans an-

gle value on the healthy elbow was assessed, and as a good anatomical reconstruction of the injured elbow fractures considered value of Baumans angle 75 5 .

Based on the average values

we assessed that in both groups adequate anatomical reposition was mostly achieved.

6. CONCLUSION

Baumans angle measurement is important for assessing the adequacy of supracondylar fracture reduction. Baumans angle correlates well with the carrying angle and can be used as an indicator of the potential occurrence of cosmetic complications. Carrying angle of uninjured arm measured when reviewing a child who has suered supracondylar fracture, can serve as a useful parameter in the assessment of real Baumans angle, and thus the adequacy of repositioning the injured hand.

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