THE CARRYING ANGLE OF ELBOW-A CORRELATIVE AND COMPARATIVE STUDY

Abstract

Background and Objectives: The angle formed by the axes of the arm and the axes of forearm when the elbow is fully extended and forearm is supinated that obtuse angle is known as " carrying angle ". Carrying angle evaluation is important to identify deformities of elbow. The present study aimed Measure and correlation of carrying angle with various parameters in young males and females. Materials and methods: The present study includes 220 (110 females & 110 males) healthy students of MBBS from KBNIMS, Gulbarga, belongs to Karnataka were selected and ages groups is 18 to 22 years. Goniometry is used for measurement of carrying angle. Height measured in normal anatomical standing posture and length of forearm measured with measuring tape. Measurements were documented and statistically analyzed. Spearman's correlation use to get relationship between parameters. Result: In females there was a significant positive correlation (p<0.05) of age with carrying angle of both sides, height was negatively correlated with carrying angle of both sides, no correlation between length of forearm with coring angle. In males Age and Height were not correlated with carrying angle but, the length of the forearm was significantly negatively correlated with carrying angle of both sides (p<0.05). Greater carrying angle was found in females. Conclusion: Carrying angle increases with age and greater in females may be because Olecranon‐coronoid angle exhibiting high sexual dimorphism may be one of the causes and it may also considered as secondary sexual characteristic. Carrying angle measurement helpful in reconstruction of elbow disorders observed after treatment of distal humerus fractures and evaluating praumatic elbow injuries.

Full text

Jyothinath Kothapalli et al
THE CARRYING ANGLE OF ELBOW- A CORRELATIVE AND COMPARATIVE STUDY
Int J Cur Res Rev, Apr 2013/ Vol 05 (07)
Page 71
IJCRR
Vol 05 issue 07
Section: Healthcare
Category: Research
Received on: 25/02/13
Revised on: 16/03/13
Accepted on: 05/04/13
THE CARRYING ANGLE OF ELBOW- A CORRELATIVE AND
COMPARATIVE STUDY
Jyothinath Kothapalli1, Pradeepkumar H. Murudkar1, Lalitha Devi Seerla2
1Department of Anatomy, Khaja Bandanawaz Institute of Medical Sciences, Gulbarga,
Karnataka, India
2Department of Biochemistry, Bidar Institute of Medical sciences (Govt. of Karnataka),
Bidar, Karnataka, India
E-mail of Corresponding Author: kjyothinath@gmail.com
ABSTRACT
Background and Objectives: The angle formed by the axes of the arm and the axes of forearm when
the elbow is fully extended and forearm is supinated that obtuse angle is known as “carrying angle”.
Carrying angle evaluation is important to identify deformities of elbow. The present study aimed
Measure and correlation of carrying angle with various parameters in young males and females.
Materials and methods: The present study includes 220 (110 females & 110 males) healthy students
of MBBS from KBNIMS, Gulbarga, belongs to Karnataka were selected and ages groups is 18 to 22
years. Goniometry is used for measurement of carrying angle. Height measured in normal anatomical
standing posture and length of forearm measured with measuring tape. Measurements were
documented and statistically analyzed. Spearman’s correlation use to get relationship between
parameters.
Result: In females there was a significant positive correlation (p<0.05) of age with carrying angle of
both sides, height was negatively correlated with carrying angle of both sides, no correlation between
length of forearm with coring angle. In males Age and Height were not correlated with carrying angle
but, the length of the forearm was significantly negatively correlated with carrying angle of both sides
(p<0.05). Greater carrying angle was found in females.
Conclusion: Carrying angle increases with age and greater in females may be because
Olecranon‐coronoid angle exhibiting high sexual dimorphism may be one of the causes and it may also
considered as secondary sexual characteristic. Carrying angle measurement helpful in reconstruction of
elbow disorders observed after treatment of distal humerus fractures and evaluating praumatic elbow
injuries.
Keywords: Carrying angle, Elbow joint. Sexual dimorphism, Trochlear angle
INTRODUCTION
The elbow joint is formed between the humerus
in the upper arm and the radius and ulna in the
forearm and allows the hand to be moved towards
and away from the body. When the arm is
extended forward, the humerus and forearm are
not perfectly aligned a deviation occurs laterally
towards the long axis of the arm, which is
referred as the "carrying angle" (1).
The carrying angle apparently develops in
response to pronation of the forearm and keeps
the swinging upper extremity away from the side
of the pelvis during walking (2). William et al
suggested that the angle is formed by the medial
edge of trochlea of humerus partly projects nearly
6 mm below the lateral edge & the oblique
superior articular surface of the coronoid process
which is not set at right angle to the shaft of ulna

Jyothinath Kothapalli et al
THE CARRYING ANGLE OF ELBOW- A CORRELATIVE AND COMPARATIVE STUDY
Int J Cur Res Rev, Apr 2013/ Vol 05 (07)
Page 72
(3). Some studies showed that the inner lip of
trochlea of humerus is a ridge groove deeper in
distally anteriorly so ulna is deflected in full
extension by this ridge (4, 5).
Women on average have smaller shoulders and
wider hips than men, which may be one reason
for more acute carrying angle. A more recent
study based on a sample size of 333 individuals
from both sexes concluded that carrying angle is
a suitable secondary sexual characteristic. The
olecranon- coronoid angle shows high sexual
dimorphism and it may be one of the causes of
sexual difference observed in carrying angle (6).
The evaluation of carrying angle is also essential
for handling and monitoring of traumatic lesions
that affect the pediatric elbow (7). The increased
carrying angle may lead to elbow instability and
pain during exercise or in throwing sports and
may reduce elbow flexion, dislocation, fracture
when fall on outstretched hand and fracture of
distal humeral epiphysis (8, 9, 10) and also
important anthropologically for sex
differentiation in skeletal remains and reduction
of fractures complication of supracondylar
fracture and may result in cosmetic deformity and
for designing total elbow prosthesis (23).
Hence, the present study aimed to study the
difference in carrying angle between sex (i.e.,
Male & female) and to find out any correlation of
carrying angle with different parameters like age,
height, length of the fore arm as this helps
orthopedic surgeon for correction of cubitus
varus deformity occurring after malunited
supracondylar fracture of humerus.
MATERIAL AND METHODS
After informed consent, 220 (110 female & 110
male) asymptomatic, healthy students of M.B.B.S
of Khaja Bandanawaz institute of Medical
sciences, Gulbarga belonging to various regions
of Andhra Pradesh, Karnataka were recruited for
the study. There ages ranged between 18 to 22
years. Medical students of this age group were
selected as subject because of easy availability.
Demographical data was obtained from each
subject including age. The students who had
previous elbow injuries as well as congenital
anomalies about the elbow were excluded from
study. The study was designed to include subjects
criteria was those with asymptomatic of any
deformity, surgeries or fractures around the
elbow joint and right handed individuals.
An improvised instrument goniometry was used
to measure the carrying angle from both upper
limbs of right and left side. The fixed arm placed
on the median axis of the upper arm, the movable
arm adjusted as to lie on the median axis of
forearm and the angle read on the goniometer.
Height was measured in standing, erect,
anatomical position from vertex to heel with bare
foot. Measuring tape was used to measure the
length of forearm and technique used for
measuring carrying angle is universally accepted.
Measurements were documented and statistical
analysis was done to get mean, and spearman’s
correlation Analysis was done to determine any
possible relationship between age, height and
length of forearm with carrying angle.
RESULTS
Table: 1 shows there was a significant difference
in carrying angle of the two sides of the upper
limbs both in males and females and a significant
greater carrying angle was found in females. It
was observed that the carrying angle of right limb
was greater than left in both sexes. Similarly the
right length of the forearm was significant than
the left in both males and females.
In the present study we have done spearmen’s
correlation analysis to observe relationship
between various parameters in both sexes.
Table: 2 shows there was a significant positive
correlation (p<0.05) of age with carrying angle of
both sides in females. Height was negatively
correlated with carrying angle of both sides but
not significant similarly there was no correlation
between length of forearm with carrying angle in
females.

Jyothinath Kothapalli et al
THE CARRYING ANGLE OF ELBOW- A CORRELATIVE AND COMPARATIVE STUDY
Int J Cur Res Rev, Apr 2013/ Vol 05 (07)
Page 73
In Males Age and Height were not correlated
with carrying angle but, the length of the forearm
was significantly negatively correlated with
carrying angle of both sides (p<0.05) shown in
Table: 3.
DISCUSSION
Apes and humans are distinguished from other
primate species in possessing carrying angle at
the elbow. The evolution of a carrying angle in
apes is related to the need to bring the center of
mass of the body beneath the supporting hand
during suspensory locomotion as seen in lower
limbs of humans in which the valgus knee brings
the foot nearer the center of mass of the body
during the single limb support phase of walking
(11).
In the present study we observed that carrying
angle of females (13.54±6.44) is greater than
males (12.09±4.66) our study was in line with
studies like Khare GN et al (12) showed that
carrying angle was more in females and they
concluded that the carrying angle does not help in
keeping the forearm away from the side of pelvis
during walking, the forearm is pronated and
carrying angle disappears in pronation of
forearm. Fick (13) claimed that the external
deviation of the forearm is because of two
powerful muscles brachioradialis and extensor
carpi radialis longus. These muscles as they
located at the radial side abduct the forearm
radially and contribute to the formation of the
carrying angle. This ‘‘muscular theory’’ explains
carrying angle fact that (a) in individuals of
athletic and obese constitution, the angle is more
as the muscles are well developed, and (b) in
older individuals the angle is more as muscles
are stronger. But, in many cases, the muscular
theory cannot explained like the carrying angle is
more obvious in women, in whom the muscles
are less developed than in men. This may be
inferior one-third of the shaft of the female
humerus appears to have a slight radial deviation,
which causes a more carrying angle in women
(14). Aebi et al, Paraskevas G et al. (15,16)
concluded that the brachial angle is similar in
both sexes, but the ulnar angle of the elbow joint
is smaller in women than in men, which causes a
more carrying angle in women. Hubscher (14)
noted that the angle is very similar in boys and in
men, but varies in females with age, he explained
that the hormonal factor may influence the
carrying angle in women. Emami et al &
Tukenmez et al (17, 18) found that carrying angle
increases with age because of skeletal maturation
and it is always greater on dominant side.
Our study was in contrast with studies like Beals
et al (19) carrying angle increases with age, but
same in each gender, but the study was done
radiographically. Similarly, Dai et al (20) did not
find any difference in carrying angle between
boys and girls this variability may be because of
different measurement techniques, races and
number of cases.
Hence, Most of the studies have focused on cause
of formation of carrying angle, difference in sex
and age but little attention has given to correlate
the carrying angle with various parameters. In the
present study we made an effort to find out the
correlation of carrying angle with age, height and
length of forearm and found that in females the
carrying angle significantly positively correlated
with age, negatively but not significantly
correlated with height and no correlation was
found with length of forearm. In males the
carrying angle was correlated with age and height
but, negatively significantly correlated with
length of forearm.
Our study was in agreement with study of
Ruparelia et al (21) found that the height and
forearm length both are more in males than
females. In contrast to this average carrying angle
is more in females than males, the findings
similar to present study they explained that if
height & length of ulna is lesser then in shorter
person the medial part of trochlear notch of ulna
goes more away from the medial flange of
trochlea which can now grow more than in a

Jyothinath Kothapalli et al
THE CARRYING ANGLE OF ELBOW- A CORRELATIVE AND COMPARATIVE STUDY
Int J Cur Res Rev, Apr 2013/ Vol 05 (07)
Page 74
person with longer forearm, leading to greater
carrying angle.
In present study in females there was no
relationship of carrying angle with forearm length
and in males the forearm length increases the
carrying angle decreases we proposed an
explanation that the carrying angle depend on
greater the length of the forearm bone lesser is
the angulation of proximal articulation of
proximal articular surface, therefore lesser is the
carrying angle. Shorter persons therefore have
smaller carrying angles than taller persons.
The study of carrying angle has much clinical
significance like extent of the carrying angle is
used to determines the type of fracture that a
child suffers when falling on an outstretched hand
and also cubitus varus deformity can be
prevented. The increased carrying angle may also
leads to ulnar neuropathy. First, is it increase
angulation of the ulnar nerve pathway and
increase the tension & chronic stretching injury
of the ulnar nerve at the elbow. Second, the ulnar
nerve is angulates two heads of the flexor carpi
ulnaris muscle by forward movement of the ulnar
nerve resulting from forward movement of the
medial head of the triceps brachii muscle in
patients with cubitus valgus or cubitus varus
deformity (22).
CONCLUSION
In our results are consistent with the literature
that the carrying angle increases with age and
carrying angle is greater in females because
Olecranon‐coronoid angle exhibiting high sexual
dimorphism may be one of the causes of sexual
dimorphism observed in carrying angle and it
may be considered as secondary sex
characteristic in female. The highest value of this
angle in the female gender would be justified by
the presence of ligamentous laxity also.
Knowledge of the measurement of the elbow
carrying angle and of its variations is important
when evaluating traumatic elbow injuries in
childhood and in adolescence and other elbow
disorders that require reconstruction or
arthroplasties. Increased carrying angle may be a
risk factor for nontrauma- related ulnar
neuropathy.
ACKNOWLEDGEMENT
All the authors are thankful to Miss. J.
Ratnapriyanka for her support. We are also
thankful to Mr. Md Shahid and students of
MBBS of KBNIMS for his help. Authors also
acknowledge the immense help received from the
scholars whose articles are cited and included in
references of this manuscript. The authors are
also grateful to authors / editors / publishers of all
those articles, journals and books from where the
literature for this article has been reviewed and
discussed.
REFERENCES
1. Snell RS. Clinical Anatomy, 7th ed.
Philadelphia, PA: Lippincott Williams &
Wilkins; 2004:551.
2. Khare GN, Goel SC, Saraf SK, Singh G,
Mohanty C. New observations on carrying
angle. Indian J Med Sci. 1999; 53:61–67.
3. Williams A, Standring S, Ellis H, Haely J
2005 Gray’s Anatomy.
4. Last RJ 1978 Anatomy – regional and
applied 6th edn London. Churchill
Livingstone Longman.
5. Decker Gog 1986 Lee Mce Gregor’s synopsis
of Surgical Anatomy 12th Edn. Bristol : John
Wright and Sons Ltd.
6. Purkait R, Chandra H, An anthropometric
investigation into the probable cause of
formation of carrying angle: a sex indicator,
Journal of Indian Academy of Forensic
Medicine, 2004, 26(1):19–23.
7. Balasubramanian P, Madhuri V, Muliyil J.
Carrying angle in children: a normative
study. J PediatrOrthop B. 2006;15:37-
40.Punia Rs, Sharma R, Usmani Ja, The
carrying angle in an Indian population, J Anat
Soc India, 1994, 43(2):107–110.

Jyothinath Kothapalli et al
THE CARRYING ANGLE OF ELBOW- A CORRELATIVE AND COMPARATIVE STUDY
Int J Cur Res Rev, Apr 2013/ Vol 05 (07)
Page 75
8. Cain EL Jr, Dugas JR, Wolf RS, Andrews JR.
Elbow injuries in throwing athletes: a current
concepts review. Am J Sports
Med.2003;31:621–635.
9. Hutchinson MR, Wynn S. Biomechanics and
development of the elbow in the young
throwing athlete. Clin Sports Med. 2004;
23:531–544.
10. Van Roy P, Baeyens JP, Fauvart D, Lanssiers
R, Clarijs JP. Arthro-kinematics of the elbow:
study of the carrying angle. Ergonomics.
2005; 48:1645–1656.
11. Ćwirko-Godycki M, Sexing skeletal remains.
In: Krogman Wm (Ed), The human skeleton
in forensic medicine, 3rd edition, Charles C
Thomas, Illinois, 1978, 112–152.
12. Khare Gn, Goel Sc, Saraf Sk, Singh G,
Mohanty C, New observations on carrying
angle, Indian J Med Sci, 1999, 53(2):61–67.
13. Fick R (1911) Handbuch der Anatomie und
Mechanik der Gelenke. Fischer, Jena
14. Hubscher C (1899) Der Ellbogenwinkel.
Dtsch Z Chir 53:445
15. Aebi H (1947) Der Ellbogenwinkel, seine
Beziehungen zu Geschlecht, Korperbau und
Huftbreite. Thesis, University of Basle
16. Paraskevas G, Papadopoulos A, Papaziogas
B, Spanidou S, Argiriadou H, Gigis J, Study
of the carrying angle of the human elbow
joint in full extension: a morphometric
analysis, Surg Radiol Anat, 2004, 26(1):19–
23.
17. M.j. Emami, f. Abdinejad, s. Khodabkhshi,
m. Amini, Andb. Naseri the normal carrying
angle of the elbow. In shiraz mjiri, 1998, 12
(1):37-39.
18. Mehmet Tukenmez, Huseyin Demirel, Sitki
Percin, Gunduz Tezeren. 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.
19. Beals RK. The normal carrying angle of the
elbow. A radiographic study of 422 patients.
Clin Orthop 1976; (119):194-6.
20. Dai L. Radiographic evaluation of Baumann
angle in Chinese children and its clinical
relevance. J Pediatr Orthop B 1999; 8:197-9.
21. Srushti Ruparelia, Shailesh Patel, Ankur
Zalawadia, Shaival Shah, S. V. Patel. Study
Of Carrying Angle And Its Correlation With
Various Parameters. NJIRM 2010; 1(3):28-
32.
22. Hui JH, Torode IP, Chatterjee A. Medial
approach for corrective osteotomy of cubitus
varus: a cosmetic incision. J Pediatr Orthop.
2004; 24:477–481.
23. Punia Rs, Sharma R, Usmani Ja, The carrying
angle in an Indian population, J Anat Soc
India, 1994, 43(2):107–110.
Table: 1 Shows Demographic values and carrying angle of both sexes
Sex
side
Carrying angle
(in degree)
Length of forearm
(in cm)
Height (in cm)
Age
Range
Mean±SD
Range
Mean±SD
Range
Mean±SD
Range
Mean±SD
Male
Right
5-22
12.09±4.66
25-31
28.07±1.48
164-188
172.83±6.75
18-22
19.89±1.36
Left
5-19
10.20±4.53
25-30
27.97±1.35
Female
Right
4-27
13.54±6.44
23-29.5
26.12±1.45
148-170
159.18±6.42
18-22
19.88±1.37
Left
4-25
11.90±5.61
23-29
25.81±1.57

Jyothinath Kothapalli et al
THE CARRYING ANGLE OF ELBOW- A CORRELATIVE AND COMPARATIVE STUDY
Int J Cur Res Rev, Apr 2013/ Vol 05 (07)
Page 76
Table-2 Spearman’s correlation coefficient Analysis of female group:
Variables
CORRELATION COEFFICIET (ρ)
p – VALUE
Age and carrying angle of right
0.249**
0.05*
Age and carrying angle of left
0.247**
0.04*
Height and carrying angle of right
-0.083
0.38
Height and carrying angle of left
-0.057
0.55
Forearm length of right and carrying angle of right
0.188
0.49
Forearm length of left and carrying angle of left
0.216
0.23
* - Statistically significant, ρ = spearman’s correlation coefficient
Table-3 Spearman’s correlation coefficient Analysis of Male group:
Variables
CORRELATION COEFFICIET (ρ)
p – VALUE
Age and carrying angle of right
0.017
0.85
Age and carrying angle of left
0.072
0.45
Height and carrying angle of right
0.014
0.88
Height and carrying angle of left
-0.030
0.75
Forearm length of right and carrying angle of right
-0.199*
0.03*
Forearm length of left and carrying angle of left
-0.198*
0.03*
* - Statistically significant, ρ = spearman’s correlation coefficient