The Journal of Bone and Joint Surgery (American). 2009;91:2188-2193.
doi:10.2106/JBJS.H.01316
© 2009 The Journal of Bone and Joint Surgery, Inc.
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Relationship of the Anterior Humeral Line to the Capitellar Ossific Nucleus: Variability with Age

Martin J. Herman, MD1, Matthew J. Boardman, DO2, Justin R. Hoover, MD3 and Ross S. Chafetz, PT, DPT, MPH4

1 Department of Orthopaedics, St. Christopher's Hospital for Children, Erie Avenue at Front Street, Philadelphia, PA 19134. E-mail address: martin1.herman{at}tenethealth.com
2 Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, 4170 City Avenue, Philadelphia, PA 19131
3 Department of Orthopaedics, University of South Carolina, Two Medical Park, Suite 404, Columbia, SC 29203
4 Shriners Hospital for Children, 3551 North Broad Street, Philadelphia, PA 19140

Investigation performed at St. Christopher's Hospital for Children, Philadelphia, Pennsylvania

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Background: The anterior humeral line is used to assess displacement and the adequacy of reduction of supracondylar humeral fractures in children. It is said to pass through the middle third of the capitellum in the elbow of a normal child. Few reports in the published literature have discussed this measurement, and the intra-rater and inter-rater reliability of the measurement is not known. The purposes of the present study were to define the position of the anterior humeral line in normal, skeletally immature elbows and to determine the intra-rater and inter-rater reliability of this parameter.

Methods: On two occasions, three observers (a pediatric orthopaedic surgeon, a senior orthopaedic resident, and a senior medical student) recorded the location of the anterior humeral line as it passed through the capitellum as seen on the lateral radiographs of thirty normal elbows in children ranging in age from four months to three years and eleven months and thirty normal elbows in children ranging in age from four to nine years. For these measurements, the capitellum was divided into three regions: the anterior third, the middle third, and the posterior third. All observers received written instructions, and identical rulers were used to make the measurements.

Results: Each observer made 120 measurements. Overall, 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 children younger than four years of age, the line passed nearly equally through either the anterior or middle third of the capitellum. In older children, the anterior humeral line passed through the middle third in 62% of the elbows. Overall, intra-rater reliability and inter-rater reliability were moderate to substantial.

Conclusions: The anterior humeral line passes through the middle third of the capitellum in the majority of normal children. In children younger than four years of age, it passes nearly equally through the anterior or middle third of the capitellum, whereas in older children it more consistently passes through the middle third of the capitellum. The surgeon must be aware of the variability of the location of the anterior humeral line with age when utilizing it to assess radiographs of the elbow in children after an injury or after the reduction of a displaced supracondylar fracture.


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