To the Editor:
We read the recent work of Skaggs and his co-authors(1) with great
interest, and commend them for their excellent paper. We
agree completely with their main point that lateral-entry pinning is the
treatment of choice for nearly all displaced supracondylar humeral
fractures. Beyond this we would like to raise two cogent issues prompted
by their work.
First, it has been our contention for quite some time that modern
approaches to supracondylar humeral fracture care have dramatically
diminished associated complications (2,3). In
fact, we feel that the most common complication following the operative
care of these injuries is now infection. This is borne out by the present
series from Children’s Hospital Los Angeles. In light of this we feel
that Skaggs et al. FIGURES 1-A and 1-B deserve further discussion. Each figure depicts
one or two intra-articular pins. We acknowledge that at times the personality of the
fracture may dictate such pin placement, but when circumstances allow,
extra-articular pins are always more desirable. Intra-articular pins make
any infection (like the one pin tract infection reported by Skaggs) a
possible harbinger of septic arthritis.
We have some experience with a
different lateral pin tactic (4) whereby one of the two lateral pins is
started superior to the fracture site and directed from the lateral
supracondylar ridge across the fractures site into the medial epicondyle.
In selected cases this may achieve fracture stability and avoid intra-
articular pin placement.
Second, Skaggs, et al, have described Baumann’s angle as an angle having a “range of 9 degrees to 26 degrees” (1). This actually represents the complement of Baumann’s angle. Ernst Baumann published his
experience with supracondylar fractures in the German literature in 1929 (5). In it he clearly depicts an angle (Figure A) on the AP radiograph formed by the intersection of a line drawn through the long axis of the shaft of the humerus and a second line drawn along the flat metaphyseal region adjacent to the capitellar growth plate, thus it is a humerocapitellar angle.
Fig. A
Baumann considered the normal value of his angle to vary from 75 degrees to 80 degrees. Many other authors have studied the utility of this angle (6,7,8,9) including Williamson and
his Australian co-authors who studied the Baumann angle in 114 children aged 2-13 years and established that the average measurement was 72 degrees (with a 95% confidence interval from 64 degrees-81 degrees)(10).
Recently Acton and McNally dug into the history of the Baumann angle and they found that Baumann was well aware of the complement of the humerocapitellar angle and thought that it roughly
corresponded to the anatomic carrying angle of the elbow. (11). We see this second point as a technical one for purposes of clarity and respect for history - as the directly proportional relationship between Baumann’s angle (or the “shaft-physeal angle” as suggested by Acton & McNally) and its complement does not change the main point of Skaggs' important paper.
1 Skaggs DL, Cluck MW, Mostofi A, et al. Lateral-Entry Pin Fixation in
the Management of Supracondylar Fractures in Children. J Bone Joint Surg
2004;86-A:702-707.
2 Mehlman CT, Crawford AH, McMillion TL, et al. Operative Treatment of
Supracondylar Fractures of the Humerus in Children: The Cincinnati
Experience. Acta Orthop Belgica 1996;62(Suppl I):41-50.
3 Mehlman CT, Strub WM, Roy DR, et al. The Effect of Surgical Timing on
the Perioperative Complications of Treatment of Supracondylar Humeral
Fractures in Children. J Bone Joint Surg 2001;83-A:323-327.
4 D'Souza, L., et al. Supracondylar Humeral Fractures in Children. J. Bone Joint Surg 1996; 16:678-679.
5 Baumann E. Contributions to the Knowledge of Fractures About the
Elbow Joint. Bietrage Klin Chir (Bruns Bietrage) 1929;146:1-50.
6 Camp J, Ishizue K, Gomez M, et al. Alteration of Baumann’s Angle by
Humeral Position: Implications for Treatment of Supracondylar Humerus
Fractures. J Pediatr Orthop 1993;13:521-525.
7 Dai L. Radiographic Evaluation of Baumann Angle in Chinese Children
and Its Clincial Relevance. J Pediatr Orthop (Part B) 1999;8:197-199.
8 Keenan WNW, Clegg J. Variations of Baumann’s Angle With Age, Sex, and
Side: Implications for Its Use in Radiological Monitoring of Supracondylar
Fracture of the Humerus in Children. J Pediatr Orthop 1996;16:97-98.
9 Worlock P. Supracondylar Fractures of the Humerus: Assessment of
Cubitus Varus by the Baumann Angle. J Bone Joint Surg-Br 1986;68:755-757.
10 Williamson DM, Coates CJ, Miller RK, et al. Normal Characteristics of
the Baumann (Humerocapitellar) Angle: An Aid in Assessment of
Supracondylar Fractures. J Pediatr Orthop 1992;12:636-639.
11 Acton JD, McNally MA. Baumann’s Confusing Legacy. Injury 2001;32:41-
43.
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