SHOULDER/ELBOW

ORTHOPEDICS November 2005;28(11):1360.

Variation of Carrying Angle With Age, Sex, and Special Reference to Side
by Erhan Yilmaz, MD; Lokman Karakurt, MD; Oktay Belhan, MD; Mehmet Bulut, MD; Erhan Serin, MD; Mustafa Avci, MD

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ABSTRACT
We measured the carrying angle using a universal full-circle manual goniometer on the dominant and non-dominant extremity of the elbow in 1275 healthy volunteers (631 males, 644 females) with a mean age of 22.8715.99 years (range: 2-91 years). In the right arm dominant group, right carrying angle was 11.253.73 and left carrying angle was 10.573.63 (P<.001). in left arm dominant group, right carrying angle was 10.653.99 and left carrying angle was 12.934.22 (P<.001). the carrying angle of dominant arm was found to be significantly higher than the nondominant arm in both sexes. the carrying angle of dominant and non-dominant arms were found to be significantly higher in patients aged >14 years than that of patients aged <14 years; females ranked higher than males.

The carrying angle of the elbow is the clinical measurement of varus-valgus angulation of the arm with the elbow fully extended and the forearm fully supinated. The intersection of the line along the mid-axis of the upper arm and the line along the mid-axis of the forearm defines this angle. With experience, the orthopedist may be able to accurately estimate angular measurements, but most accurate measurements of carrying angle usually are obtained with a hinged goniometer and recorded in degrees.
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Figure 1: The position of the

Change in the carrying angle with age and gender was reported.
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3-6

Khare et

goniometer on the volar surface of the arm and forearm with the elbow extended and the forearm supinated.
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al noted that the carrying angle is greater in shorter persons compared to taller persons and the lesser the forearm bone lengths the greater the carrying angle will be. However, no study exists in the literature regarding carrying angle differences in dominant and non-dominant arms. This study investigated the carrying angle differences according to the dominant and non-dominant arms and the effects of age and gender to this angle difference.

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Materials and Methods

This study is comprised of 1275 healthy volunteers with an average age of 22.8715.99 years (range: 2-91 years). The carrying angle measurements were performed first on the dominant extremity and then on the non-dominant extremity. Individuals with a history of malunion or growth disturbance involving either upper extremity were excluded from the study. The carrying angle was measured with a full-circle manual goniometer made of flexible clear plastic with 35-cm long arms. This device fulfilled the requirements of a universal goniometer. It was positioned on the volar surface of the arm and was aligned with the mid-axis of the humerus to the extended elbow and mid-axis of the fully supinated forearm (Figure 1). Two examiners (M.B. and M.A) evaluated each of the volunteers independently and the study was performed in two stages. A pilot study was carried out initially to test the goniometer and to ascertain if the measurements were associated with acceptably low intra-examiner and inter-examiner errors. Before the measurements were made, the goniometer was determined to be accurate within 1 of the measurement of the known angles. The two examiners evaluated 30 volunteers, who were not included with the 1275 volunteers, independently. The first examiner made sequential measurements of the carrying angle. The measurements were recorded, and the goniometer was reset to 0. The second examiner then measured the carrying angle of the same subject, in the same sequence. The sequence was repeated so that each examiner measured the carrying angle of each patient twice. Intra-examiner reliability was determined by a comparison of the first and second measurements by each examiner. Inter-examiner reliability was determined by a comparison of the first measurements by the first examiner with the first measurements by the second examiner for each volunteer. The second portion of the study involved measurement of the carrying angle of the dominant and non-dominant elbow in 1275 healthy volunteers with use of the same protocol as in the pilot study. Chi-square, paired t, and unpaired t tests were used to compare the values of the carrying angles. A Pvalue <.05 was considered significant.

Figure 2: *P<.001 between 1-2, 3-4, 2-4. P>.05 between 2-3. Comparison of the carrying angles of right- and left hand-dominant groups. Figure 3: ***P<.001 between 1-2 and 3-4. comparison of the carrying angles of dominant and non-dominant arms in males and females with right arm dominances.

Results
There were statistically significant no differences in the mean intra-examiner reliability and in the mean inter-examiner reliability (P>.05).

This study included 1275 volunteers, 631 males and 644 females. Right arm dominance was in 1195 (94%) volunteers and left arm dominance was in 80 (6%) volunteers. There were 586 (49%) males and 609 (51%) females in right arm dominant group, and 45 (56%) males and 35 (44%) females in left arm dominant group. There was no statistical difference between the male and female volunteers for right- and left-hand dominances (X :1.58 and P=.09). In right arm dominant group, the right carrying angle was 11.253.73 and left carrying angle was 10.573.63 (P<.001). in the left arm dominant group, the right carrying angle was 10.653.99 and the left carrying angle was 12.934.22 (P<.001) (figure 2). No significant difference was found between the right carrying angle of the right arm dominant group (11.253.73) and the right carrying angle of the left arm dominant group (10.6513.99) (P>.05). However, the left carrying angle of the left arm dominant group (12.934.22) was found to be higher than the left carrying angle of the right arm dominant group (10.573.63) (P<.001) (figure 2). In the right arm dominant group of males, the right carrying angle was 10.473.75 and the left carrying angle was 9.723.59 (P<.001). in the right arm dominant group of females, right carrying angle was 12.013.54 and left carrying angle was 11.403.46 (P<.001) (figure 3). in the left arm dominant group of males, the right carrying angle was 9.584.24 and the left carrying angle was 11.934.61 (P<.001). in the left arm dominant group of females, the right carrying angle was 12.033.21 and left carrying angle was 14.203.31 (P<.001) (figure 4). Right and left carrying angles of females with right arm dominance were found to be higher than the same carrying angles of males with right-arm dominance (P<.001). when comparing females and males with left arm dominance, right and left carrying angles were found to be higher in females than in males (P<.01 and P<.05 respectively). Group 1 had 521 volunteers (497 right arm and 23 left arm dominances) with an average age of 14 years (range: 214 years). Group 2 had 754 volunteers (697 right and 57 left arm dominances) with an average age of >14 years (range: 15-91 years). Right arm carrying angles of the right arm dominant volunteers in group 1 and group 2 were 10.613.51 and 11.723.82 respectively (P<.001). left arm carrying angles of the right arm dominant volunteers in group 1 and group 2 were 10.163.51 and 10.863.69 respectively (P<.01) (figure 5). In group 1 and group 2, left arm dominant volunteers right carrying angles were 8.833.61 and 11.393.93 respectively (P<.01), and the left carrying angles were 10.963.65 and 13.724.21 respectively (P<.01) (figure 6).
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Figure 4: ***P<.001 between 1-2 and 3-4. comparison of the carrying angles of dominant and non-dominant arms in males and females with left arm dominances. Figure 5: *P<.001 between 1-2. **P<.01 between 3-4. comparison of the right and left carrying angles of volunteers with dominant-right arms in group 1 (<14 years) and group 2 (>14 years).

Discussion

Outward angulation of the supinated forearm with the elbow extended is called the carrying angle, which is found even in utero and is completely developed in a newborn. It exhibits considerable individual variation.
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Comparisons
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for the carrying angle should be made with the contralateral side rather than with any normal standard.

A change in the carrying angle following a supracondylar fracture can result from malunion after inadequate/loss of reduction or as a result of growth disturbance at the lower end of humerus. Volunteers who had a history of malunion or growth disturbance involving either upper extremity were excluded from the study. Armstrong et al
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examined intratester, intertester, and intradevice reliability of range of motion measurements of the
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elbow and forearm. Measurement error occurred least for repeated measurements taken by the same tester with the same instrument and the most frequently when different instruments were used. To reduce the measurement error, we used a full-circle manual universal goniometer made of flexible clear plastic and all measurements were made by two examiners. The mean intra-examiner reliability was within 0.19 for each measurement and the mean interexaminer reliability was within 0.21. There are several studies that compared the muscle powers and range of joint motions between the dominant and non-dominant sides.
11-13

However, no study exists about the differences of carrying angles with reference to dominant
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and non-dominant arms. Maughan et al

trained volunteers who were able to exert a greater isometric force with the
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dominant limb than with the non-dominant limb. Gunal et al left.

found that the ranges of motion on the right side of the

upper extremity in 1000 healthy males, who were right hand dominant, were significantly smaller than those on the

Figure 6: *P<.01 between 1-2 and 3-4. comparison of the right and left carrying angles of volunteers with dominant-left arms and group 1 (<14 years) and group 2 (>14 years).

We measured the carrying angles in dominant and non-dominant arms and the carrying angle in the dominant side was found to be higher than in the non-dominant side (P<.001). the left carrying angle of the left arm dominant group was found to be higher than the left carrying angle of the right arm dominant group (P<.001). however, no significant differences were found between the right carrying angle of the right-arm dominant group and the right carrying angle of the left-arm dominant group (P>.05). The carrying angle of the dominant side measured higher than the carrying angle of the non-dominant side in men and women (P<.001). It is reported that carrying angles differ according to the sex and age.
4-6,14

Amis and Miller reported that the average

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carrying angle was 11 for adult males, 14 for adult females, and 6 for children. Smith studied the carrying angle of 150 normal children, 80 females and 70 males, aged 3 to 11 years. He found the average carrying angle to be 6.1 in the females (range: 0-12), and 5.4 in males (range: 0-11). In the literature, carrying angle is higher in women than in men. In this study, the carrying angle of dominant and non-dominant arms was found to be higher in females than in males. Right and left carrying angles in females with dominant right arm were significantly higher than in males with dominant right arm (P<.001). Beals measured the mean carrying angle in a radiographic study conducted on 422 patients. Approximately 50 male and 50 female patients were divided into four age groups: newborn to 4 years of age, 5 to 11 years, 12 to 15 years, and adults. The mean carrying angle was 15 in the newborn to 4-year-old group and increased slightly with age to reach 17.8 in adults. We also had two groups; group 1 had volunteers aged <14 years and group 2 had volunteers aged >14 years. The age brackets were deternined based on the closing time of the epiphyseal plates of medial and lateral condyle of the distal humerus. The carrying angle of dominant and non-dominant arms was found to be higher in group 2 (after the epiphyseal plates closed) than in group 1 (before the epiphyseal plates closed) (P<.01). a significant difference was noted between group 1 and group 2 for left dominant arms (P<.01), but more significant difference was found for right dominant arms (P<.001). As a result, the carrying angle of the dominant arm was found to be significantly higher than the non-dominant arm in both sexes. The carrying angles of dominant and non-dominant arms were found to be significantly higher in the volunteers aged >14 years than of those aged <14 years; and females ranked higher than males.
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References
1. Green NE. Fractures about the elbow. In: Green NE, Swiontkowski MF, Lampert R, eds. Skeletal Trauma in Children. Vol 3. 2nd ed. Philadelphia, Pa. WB Saunders Co; 1997:259-317. 2. Harring JA. The orthopaedic examination: a comprehensive overview. In: Herring JA, eds.Tachdjians Pediatric Orthopaedics. Vol 1. 3rd ed. Philadelphia, Pa: WB Saunders Co; 2002:25-61. 3. Harring JA. Tachdjians Pediatric Orthopaedics. Vol 3. 3rd ed. Philadelphia, Pa: WB Saunders Co; 2002:2164-2168. 4. Beals RK. The normal carrying angle of the elbow. A radiographic study of 422 patients. Clin Orthop. 1976; 119:194-196. 5. Amis AA, Miller JH. The elbow. Clin Rheum Dis. 1982; 8:571-593. 6. Smith L. Deformity following supracondylar fractures of the humerus. J Bone Joint Surg Am. 1960; 42:1668. 7. Khare GN, Goel SC, Saraf SK, Singh G, Mohanty C. New observations on carrying angle. Indian J Med Sci. 1999; 53:61-67. 8. King D, Secor C. Bow elbow (cubitus varus). J Bone Joint Surg Am. 1951; 33:572-576. 9. Jain AK, Dhammi IK, Arora A, Singh MP, Luthra JS. Cubitus varus: problem and solution. Arch Orthop Trauma Surg. 2000; 120:420-425. 10. Armstrong AD, MacDermid JC, Chinchalkar S, Stevens RS, King GJ. Reliability of range-of-motion measurement in the elbow and forearm. J Shoulder Elbow Surg. 1998; 7:573-580. 11. Gunal I, Kose N, Erdogan O, Gktrk E, Seber S. Normal range of motion of the joints of the upper extremity in male subjects, with special reference to side. J Bone Joint Surg Am. 1996; 78:1401-1404. 12. Gallagher MA, Cuomo F, Polonsky L, Berliner K, Zuckerman JD. Effects of age, testing speed, and arm dominance on isokinetic strength of the elbow. J Shoulder Elbow Surg. 1997; 6:340-346.

13. Maughan RJ, Abel RW, Watson JS, Weir J. Forearm composition and muscle function in trained and untrained limbs. Clin Physiol. 1986: 6:389-396. 14. Tachdijan MO. Fractures and dislocations. In: Herring J, Herring JA, Tachdjian MO, eds.Tachdjians Pediatric Orthopaedics. Vol 4. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1990:3013-3373.

Authors
Drs Yilmaz, Karakurt, Belhan, Bulut, Serin, and Avci are from the Department of Orthopedics and Traumatology, Firat University, Elazig, Turkey. Reprint requests: Erhan Yilmaz, MD, Dept of Orthopedics, Firat University, 23119 Elazig, Turkey.
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