Shared Decision-Making About Returning to Sport After Recovery From Pediatric Concussion: Clinician Perspectives.

OBJECTIVE: Describe how sports medicine clinicians support decision making about sport participation after concussion recovery with adolescent patients and their parents. Specific areas of inquiry related to how clinicians framed the decision, what factors they considered in how they approached the decision process, and how they navigated discordance within families. DESIGN: Qualitative study. SETTING: Tertiary care sports medicine clinics at 4 children's hospitals in the United States. PARTICIPANTS: Individual interviews were conducted with 17 clinicians practicing in sports medicine settings. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Semi-structured interviews explored clinician approaches to supporting decision making, with the question guide informed by components of the Ottawa Decision Support Framework. RESULTS: Clinicians routinely incorporated aspects of shared decision making (SDM) into their conversations with families. This included ensuring all parties were informed about risk and aligned behind a shared value of adolescent well-being. Mediation strategies were used to manage discordance between adolescents and their parents, and between parents. These strategies aimed to facilitate a decision that was adolescent centered. When clinicians believed that there was a medical benefit to modifying the adolescent's sport participation practices, or when they did not believe the athlete was psychologically ready to return to the sport in which they were injured, they initiated conversations about alternative activities. In such situations, they used persuasive communication practices to encourage families to strongly consider this option. CONCLUSION: The strengths and strategies used by sports medicine clinicians in this study provide a foundation for guidance or intervention development aimed at supporting SDM after concussion with adolescents and their families.

Effect of RISE Bundle implementation on school adoption of a student-centered return-to-learn program in Washington state.

BACKGROUND: Appropriate concussion care in school is vital for full recovery, but school return-to-learn (RTL) programs are lacking and vary in quality. Establishing student-centered RTL programs may reduce disparities in RTL care. OBJECTIVE: To examine the effect of RISE Bundle (Return to Learn Implementation Bundle for Schools) implementation on high school adoption of a student-centered RTL program. METHODS: A convenience sample of fourteen (4 rural and 10 urban) small and large Washington (WA) State public high schools were enrolled in a stepped-wedge study with baseline, end of study, and monthly measures over the 2021-2022 academic year. Schools identified an RTL champion who led RISE Bundle implementation in 6-week steps. Concussion knowledge and impact of RTL program on concussion care were examined. RESULTS: Ten schools (71.4%) successfully completed RISE Bundle implementation and established a functional RTL program. Self-reported concussion knowledge from RTL Champions increased post intervention. Establishing RTL programs facilitated provision of tailored accommodations, and perceived variation and inequities in RTL care were reduced. CONCLUSION: RISE Bundle implementation proved feasible, supported the establishment of a functional RTL program, and perceived to reduce disparities in concussion care in rural and urban WA State public high schools of varying sizes.

Effect of Collaborative Care for Persistent Postconcussive Symptoms on Academic Function: A Randomized Clinical Trial.

BACKGROUND: There is limited long-term data on the course of school-related problems and academic needs for youth with persistent post-concussive symptoms (PPCS). METHODS: This was a randomized trial comparing collaborative care to usual care for 200 youth 11-18 years of age with PPCS. In this report, the main outcomes were academic functioning, GPA, school absences, date of return to school, and school days missed. RESULTS: Youth were mean age of 14.7 (SD = 1.7), 62.0% female. New or worsening academic problems occurred in half of participants in both groups at 12 months after injury. Students were most concerned about grades and falling behind. There were no significant differences by study group on school problems or GPA, but number of days missed was lower in the collaborative care group compared at 3 months (12.5 [SD = 14.5] vs 16.1 days [20.4] adjusted relative risk [aRR] 0.67 [95% CI: 0.61, 0.74; p < .001]), 6 months (14.5 [22.1] vs 19.3 [26.6] aRR 0.77 [95% CI: 0.71, 0.84; p < .001]), and 12 months (16.9 [25.4] vs 19.6 [27.7], aRR 0.68 [95% CI: 0.62, 0.74; p < .001]). CONCLUSIONS: Youth with PPCS are at high risk of school problems in the year after injury.

Prevalence and Severity of Juvenile Osteochondritis Dissecans in Patients With Juvenile Idiopathic Arthritis.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is a heterogeneous group of chronic arthritides presenting in patients aged ≤16 years, with a prevalence of 16 to 150 per 100,000. Juvenile osteochondritis dissecans (OCD) is an idiopathic disease of articular cartilage and subchondral bone, has an onset age of 10 to 16 years, and often affects the knee, with a prevalence of 2 to 18 per 100,000. Currently, there are few studies that have evaluated the relationship between JIA and OCD. HYPOTHESIS: OCD is more prevalent in children with JIA, and when diagnosed in such patients, OCD often presents at an advanced state. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The medical records of patients with diagnoses of both JIA and OCD treated between January 2008 and March 2019 at a single children's hospital were retrospectively reviewed. Associations between timing of diagnoses, number and types of corticosteroid treatments, category of arthritis, timing of diagnoses, and lesion stability were examined with Spearman correlation coefficients. RESULTS: A total of 2021 patients with JIA were identified, 20 of whom (19 female, 1 male) had OCD of the knee and/or talus for a prevalence of 1 in 100 or 1000 in 100,000, or approximately 50 to 500 times that of the general population. These 20 patients had a total of 28 OCD lesions: 43% (9 femur, 3 talus) were radiographically stable over time, 50% (10 femur, 2 patella, 2 talus) were unstable at initial diagnosis, and 7% (2 femur) were initially stable but progressed to unstable lesions despite drilling. Twelve patients (60%) underwent surgery: 4 (20%) with stable femoral lesions for persistent symptoms despite prolonged nonoperative treatment and 8 (40%) for treatment of their unstable lesions (femoral and patellar). Within our study design, we could identify no significant associations between lesion stability and timing of diagnoses, number of joint injections, or limb deformities, nor were there associations between timing of JIA and OCD diagnoses and category of arthritis. CONCLUSION: In our population of patients with JIA, OCD lesions were found to be 50 to 500 times more prevalent when compared with published rates in the general population and often presented at an advanced state, with instability or delayed healing requiring surgery for stabilization or resolution of symptoms.

Effect of Collaborative Care on Persistent Postconcussive Symptoms in Adolescents: A Randomized Clinical Trial.

Importance: Despite the high level of impairment for adolescents with persistent postconcussive symptoms, few studies have tested whether such problems can be remediated. Objective: To examine whether collaborative care treatment is associated with improvements in postconcussive, quality of life, anxiety, and depressive symptoms over 1 year, compared with usual care. Design, Setting, and Participants: The Collaborative Care Model for Treatment of Persistent Symptoms After Concussion Among Youth II Trial was a randomized clinical trial conducted from March 2017 to May 2020 with follow-up assessments at 3, 6, and 12 months. Participants were recruited from pediatric primary care, sports medicine, neurology, and rehabilitation clinics in western Washington. Adolescents aged 11 to 18 years with a diagnosed sports-related or recreational-related concussion within the past 9 months and with at least 3 symptoms persisting at least 1 month after injury were eligible. Data analysis was performed from June to September 2020. Interventions: The collaborative care intervention included cognitive behavioral therapy and care management, delivered mostly through telehealth, throughout the 6-month treatment period, with enhanced medication consultation when warranted. The comparator group was usual care provided in specialty clinics. Main Outcomes and Measures: Primary outcomes were adolescents' reports of postconcussive, quality of life, anxiety, and depressive symptoms. Secondary outcomes were parent-reported symptoms. Results: Of the 390 eligible adolescents, 201 (51.5%) agreed to participate, and 200 were enrolled (mean [SD] age, 14.7 [1.7] years; 124 girls [62.0%]), with 96% to 98% 3- to 12-month retention. Ninety-nine participants were randomized to usual care, and 101 were randomized to collaborative care. Adolescents who received collaborative care reported significant improvements in Health Behavior Inventory scores compared with usual care at 3 months (3.4 point decrease; 95% CI, -6.6 to -0.1 point decrease) and 12 months (4.1 point decrease; 95% CI, -7.7 to -0.4 point decrease). In addition, youth-reported Pediatric Quality of Life Inventory scores at 12 months improved by a mean of 4.7 points (95% CI, 0.05 to 9.3 points) in the intervention group compared with the control group. No differences emerged by group over time for adolescent depressive or anxiety symptoms or for parent-reported outcomes. Conclusions and Relevance: Although both groups improved over time, youth receiving the collaborative care intervention had fewer symptoms and better quality of life over 1 year. Intervention delivery through telehealth broadens the reach of this treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT03034720.

Community-Engaged Approach to the Development and Implementation of a Student-Centered Return to Learn Care Plan After Concussion.

BACKGROUND: Current return to learn (RTL) after concussion guidelines lack specificity for individualized student care, limiting potential for adoption and implementation. We used a community-engaged research framework to develop and evaluate the implementation of a student-centered care plan that assists school personnel in facilitating RTL. METHODS: We used best-practice RTL guidelines and input from administrators and medical experts to iteratively develop a flexible student-centered care plan. Thirteen schools participated. Coding completion of care plans indicated feasibility and fidelity; interviews with RTL coordinators indicated acceptability. RESULTS: The care plan includes educational materials, symptom checklists, and guidelines for classroom adjustments linked to student symptoms. Care plans were initiated for 24 (70.6%) of 34 students with concussions, indicating feasibility. Fidelity was high, with the following subsections completed: Action Checklist (90%), Symptom Evaluation (91%), Temporary Adjustment Recommendations (95%). Qualitative analysis of interviews suggested care plans were acceptable and facilitate consistent communication, prioritization of individual needs of students, and increased ability to delegate tasks to other school staff. CONCLUSIONS: Implementation of a student-centered, individually tailored care plan for RTL is feasible and acceptable in public high schools. Future research should examine how to expediently initiate student-centered concussion care plans after diagnosis to optimize recovery.

Use of diffusion tension imaging in the evaluation of pediatric concussions.

OBJECTIVE: To evaluate whether quantitative metrics of white matter fractional anisotropy (FA) and mean diffusivity (MD) were different in patients presenting to our clinic with persistent symptoms after a concussion. DESIGN: Matched control retrospective study. SETTING: Primary not-for-profit Institution. PATIENTS: Consecutive patients seen at a primary care institution's Sports Concussion Clinic for sport-related concussion that underwent diffusion tensor imaging. Interventions (Independent variables): Type of sports, days from Injury, number of symptoms, weeks out when Magnetic Resonance Imaging (MRI) ordered, history of psychological issues, length of symptoms, age, sex, MRI imaging data. MAIN OUTCOME MEASURE: Difference in white matter FA and MD. RESULTS: Seventeen concussion patients, ages 9 and 17 (average = 12.5 years; median = 13 years, 11 males and 6 females), were matched with age and gender controls who had an MRI following a complaint of headache. Patients reported an average of 11.5 concussion symptoms, out of a total possible 22 and were seen at an average of 30 days post injury. No region met tract based spatial statistics criteria for significant differences between concussed and healthy control groups (all p > 0.05). Similarly, when comparing group averages from the atlas based regional summaries, no region met the 0.2 false discovery rate (FDR) threshold for significant differences (the smallest unadjusted p-values were 0.02 for MD and 0.14 for FA). CONCLUSIONS: Our results did not show measurable diffusion tensor imaging (DTI) changes with standard clinical data acquisition and quantitative processing for the individual patient. At this time DTI should not be considered a technique that can diagnose concussion within an individual subject.

Combined glue embolization and excision for the treatment of venous malformations.

BACKGROUND: The purpose of this study was to evaluate safety, technical success, and clinical outcomes of treatment for venous malformations using n-BCA glue embolization immediately prior to excision. Sixty three patients (22 male, 41 female; mean age 12 years (range 1-25)) who underwent 70 procedures for extremity and trunk venous malformations were reviewed. Indications for treatment included pain (100%), swelling (22%), and diminished range of motion (16%). Thirty seven patients (59%) had undergone prior stand-alone interventional or surgical treatment but were persistently symptomatic. Safety, technical and clinical success were retrospectively assessed. RESULTS: Embolization was technically successful in 100% of patients. Mean lesion size was 3.0 × 2.9 × 5.7 cm. Three patients (5%) underwent planned, second stage procedures for lesions intentionally not treated at the first procedure. Four patients (6%) underwent an unplanned, second stage procedure for residual disease after the primary operation. Mean and median follow-up duration were 18 and 17 months, respectively (range 3 to 35 months). Symptomatic improvement was achieved in 58 patients (92%), of whom 41 (65%) reported complete elimination of pain. There were no recognized instances of nontarget embolization or other complications of the interventional procedure. One patient required additional surgery for wound dehiscence and one patient developed an abscess requiring incision and drainage. Minor surgical complications included surgical site skin infections (n = 5) and numbness (n = 1). Mean and median surgical blood loss volumes were 131 mL and 10 mL, respectively. One patient required perioperative blood transfusion. CONCLUSIONS: Extremity and truncal venous malformations can be safely and effectively treated in a single-stage fashion using glue embolization immediately preceding excision.

GABA alterations in pediatric sport concussion.

OBJECTIVE: To evaluate whether frontal-lobe magnetic resonance spectroscopy measures of γ-aminobutyric acid (GABA) would be altered in a sample of adolescents scanned after sport concussion because mild traumatic brain injury is often associated with working memory problems. METHODS: Eleven adolescents (age 14-17 years) who had sustained a first-time sport concussion were studied with MRI/magnetic resonance spectroscopy within 23 to 44 days after injury (mean 30.4 ± 6.1 days). Age- and sex-matched healthy controls, being seen for sports-related injuries not involving the head and with no history of concussion, were also examined. GABA/creatine + phosphocreatine (Cre) was measured in left-sided frontal lobe and central posterior cingulate regions. The frontal voxel was positioned to overlap with patient-specific activation on a 1-back working memory task. RESULTS: Increased GABA/Cre was shown in the frontal lobe for the concussed group. A decreased relationship was observed in the parietal region. High correlations between GABA/Cre and task activation were observed for the control group in the frontal lobe, a relationship not shown in the concussed participants. CONCLUSIONS: GABA/Cre appears increased in a region colocalized with working memory task activation after sport concussion. Further work extending these results in larger samples and at time points across the injury episode will aid in refining the clinical significance of these observations.

Washington State's Lystedt law in concussion documentation in Seattle public high schools.

CONTEXT: The Lystedt law requires high school athletes who have sustained a concussion to be removed from practice and play and not to be allowed to return until cleared by a medical professional. OBJECTIVE: To determine the effect of the Lystedt law on injury and concussion documentation in the Seattle public high schools. DESIGN: Cross-sectional study. SETTING: Seattle public high schools. PATIENTS OR OTHER PARTICIPANTS: The numbers of students, aged 13 to 19 years in the 2008-2009, 2009-2010, and 2010-2011 school years, were 4348, 4925, and 4806, respectively. MAIN OUTCOME MEASURE(S): All injuries documented in SportsWare by athletic trainers in Seattle public high schools. We evaluated all injuries, including concussions recorded during the 2008-2009 school year, before the Lystedt law, and during the 2 school years after the law took effect (2009-2010 and 2010-2011). Incidence rates before and after the law were estimated and compared. RESULTS: The concussion rate was -1.09% in 2008-2009, 2.26% in 2009-2010, and 2.26% in 2010-2011. A comparison of relative risks showed that the incidence rates of concussions were different before and 1 year after the Lystedt law (relative risk = 2.10; 95% confidence interval [CI] = 1.50, 2.93) and 2 years after the law (relative risk = 2.10; 95% CI = 1.49, 2.93). Overall, the mean number of days out of play after 2008-2009 was almost 7 days greater after the law took effect (difference = 6.9 days; 95% CI = 0.70, 13.1). For females, the mean number of days out of play after 2008-2009 was more than 17 days in 2009-2010 (difference = 17.2 days; 95% CI = 4.81, 29.5) and was more than 6 days in 2010-2011 (difference = 6.3 days; 95% CI = 1.62, 11.0). CONCLUSIONS: The number of documented concussions more than doubled after the institution of the Lystedt law, which may be attributed to heightened awareness and closer monitoring.

Musculoskeletal screening: developmental dysplasia of the hip.

Developmental dysplasia of the hip (DDH) is common because it is present in 1 of 100 newborns. Failure to diagnose DDH and treat in infancy can result in significant long-term disability. Early diagnosis can be accomplished through a quick but careful physical examination of all newborns. Further selective screening by ultrasound is indicated for those children with risk factors for DDH, which include family history, breech presentation, and unstable hip examination at the initial newborn examination. Continued examination of the hip at all routine well-child checkups is mandatory through the first year of life because late presenting DDH may occur. Treatment with a Pavlik harness is not typically instituted in the neonate because many unstable hips stabilize without intervention, but it is indicated in children older than 2 weeks with hip instability. Ultrasound screening for infants with risk factors for DDH is recommended at age 6 weeks. Pavlik harness treatment for children with unstable hips or significant dysplasia on ultrasound is continued until the hips stabilize and show concentric reduction on imaging. With time, diagnosis and treatment evolve to accommodate the growing child. Infants who fail to respond to nonoperative management may require more extensive interventions. At any time when treatment is initiated, a DDH specialist should be involved in the patient's care. If DDH is recognized early, treatment is less invasive, and long-term effects are minimized.

Baumann angle and radial-ulnar overlap: a radiographic study to control for the angle of the x-ray beam.

BACKGROUND: Baumann's angle (BA) is the most common radiographic measurement used to assess coronal plane alignment of the distal humerus. However, it can vary greatly based on the x-ray beam angle, which can lead to multiple radiographs causing excessive radiation exposure, cost, and discomfort for the acutely injured child. The lateral capitellohumeral angle is a measure of sagittal plane alignment, and its variability has been reported. In this study, we sought to determine whether there were surrogate measures that could act as internal controls for the angle of the x-ray beam to give an accurate BA. METHODS: Elbow radiographs from uninjured children stratified by age into 6 groups were reviewed. BA and lateral capitellohumeral angle as well as several predetermined measurements that could be potential surrogate measures for the angle of the x-ray beam were performed. Statistical significance was found between BA and radial-ulnar overlap (RUO), which was analyzed further and plotted in linear graph fashion. RESULTS: The Pearson correlation coefficient (0.58) between BA and RUO was significant at P=0.001. The average BA was 71±7.2 degrees (1 SD) and the average RUO was 0.34±0.26. The following linear graph equation was obtained to define the relationship between RUO and BA: BA=12.36 (RUO)+67. Further derivation gives us an equation to "correct" BA for a given RUO: corrected BA=measured BA-12.36 (RUO-0.34). Application of this formula lessened the SD of BA from 7.2 to 5.9 degrees and decreased the percentage of BA measurements outside of 1 SD from 30% to 14%. CONCLUSIONS: RUO is a reliable surrogate measure to control for the angle of the x-ray beam and improve the reliability when measuring BA that can be easily applied in the clinical setting. CLINICAL RELEVANCE: The ability to accurately correct the BA based on a given RUO gives the physician the confidence to adequately interpret imperfect radiographs in the emergency room setting and minimize repeat radiographs.

Does using the medial or lateral humeral line improve reliability of Baumann angle measurement on plain x-ray? The effect of humeral length visualized on the x-ray.

BACKGROUND: Baumann angle (BA) is a common measure of coronal plane alignment of the distal humerus. We hypothesize that the reliability of measuring BA would be improved by using the medial and lateral cortical margins of the humerus seen on plain x-ray, rather than the estimated central humeral line, which is the "standard" technique. Further, we analyze whether the amount of humerus visible on the film improves the reliability of the method. METHODS: A total of 71 anteroposterior elbow digital radiographs from patients aged 0 to 12 were measured 3 times by 5 qualified observers. Each digital measurement included (1) BA using the estimated central humeral line; (2) BA using the medial humeral line (BA-MHL); and (3) BA using the lateral humeral line (BA-LHL). Inadequate radiographs or those showing any indication of current or previous fracture were excluded. Intraobserver reliability was estimated for each rater using a 1-way analysis of variance model and interobserver reliability of each set of measurements was estimated using a 2-way analysis of variance. RESULTS: The mean and SD for the BA, BA-MHL, and BA-LHL in females were 70.0 (6.73), 68.0 (6.84), and 72.3 (7.93), respectively, and for males 73.0 (5.22), 70.0 (5.56), and 76.0 (6.18), respectively. Intraobserver reliability (intraclass correlation coefficient) for BA, BA-MHL, and BA-LHL averaged 0.85, 0.92, and 0.90, respectively. Average interobserver reliability (intraclass correlation coefficient) for BA, BA-MHL, and BA-LHL were 0.79, 0.71, and 0.76, respectively. Intraobserver and interobserver reliability of BA and BA-LHL were significantly improved when at least 7 cm of humerus was visible on the x-ray, as compared with <7 cm visible. CONCLUSIONS: Intrarater reliability is better for both BA-LHL and BA-MHL than for standard BA (using the estimated central humeral axis). Interrater reliability was best using standard BA. Reliability of all methods is improved when >7 cm of the distal humerus is visible on the radiograph. In addition, at least 7 cm of the distal humerus on anteroposterior radiographs improves reliability of measuring BA. LEVEL OF EVIDENCE: Diagnostic study-Level II.

Sport Concussion Assessment Tool-2: baseline values for high school athletes.

BACKGROUND: Concussion head injuries are common in high school athletes. The Sport Concussion Assessment Tool-2 (SCAT2) has been recommended and widely adopted as a standardised method of evaluating an injured athlete with a suspected concussion. Sideline return to play decisions can hinge on the results of a SCAT2 score. However, most athletes will not have had baseline testing performed for comparison if injury occurs. Therefore, establishing of age-, sex- and sport-matched normative data for the high school athlete population is critical. PURPOSE: To determine baseline scores in all SCAT2 domains among high school athletes with no prior history of a concussion and to examine subgroup differences for girls and boys, age and sport to establish normative ranges. MATERIALS AND METHODS: The SCAT2 was administered to 214 high school athletes (155 males and 59 females) who participated in football, women's soccer, men's basketball, gymnastics, baseball, softball and track with no prior history of concussion. There were 111 athletes in the 13-15-year-old cohort and 103 in the 16-19-year-old group with a mean age of 15.7 years of age. In all SCAT2 domains the mean and SD of the results were determined. The domains were analysed using age, sex and sport as covariates. Component parts of the cognitive (concentration) domain (digit sequencing and months of year in reverse order) were also analysed by age, sex and sport. The percentage of high school athletes able to perform each digit-sequencing test was calculated as was the percentage of participants who could recite the months of the year in reverse order. RESULTS: The average SCAT2 score for these high school athletes was 89 of a possible 100 with a SD of 6 units. Athletes reported two or three symptoms at baseline with older students reporting more symptoms than younger ones. The average balance score was 25.82 (of 30), and all athletes were able to complete the double-leg stance. Females scored significantly higher on the balance, immediate memory and concentration scores. Concentration scores in non-concussed high school athletes were low. Only 67% of high school athletes could recite the months of the year backward and only 41% could correctly sequence 5 digits backward. Only 55% of high school football players could correctly recite the months of the year backward and 32% could sequence 5 digits. CONCLUSIONS: Non-concussed high school athletes scored near the total possible in most domains of the SCAT2 with the exception of concentration testing and balance testing. All athletes were able to complete the double-leg stance at baseline; however, there was significant variability of tandem and single-leg stance. Baseline testing is important when considering balance tests. Concentration testing in high school athletes is unreliable because of high baseline error and is likely to result in a high rate of false positives and false negatives. Return to play decisions should not rely on concentration testing without a baseline test for comparison.

Epidemiology of youth sports concussion.

The overall prevalence of concussion is high school sports is unknown. In general, concussions in this age range occur much more frequently in games than in practice. Also for sports in which both sexes participate, reported concussion rates are higher for female than male high school athletes. Recent data show that the time required for return to play and resolution of symptoms is similar for women and men. Very little is known about the epidemiology of concussions in middle school-aged athletes and younger children.

The lateral capitellohumeral angle in normal children: mean, variation, and reliability in comparison to Baumann's angle.

BACKGROUND: Angular deformity is the most common complication of supracondylar humerus fracture. Baumann's angle (BA) is an established radiographic measure of coronal plane deformity after this injury. Numerous radiographic methods have been used to assess sagittal plane deformity, however, the mean, variability, and reliability of these measures has not been established. The purpose of this study was to determine the mean, SD, and intraobserver/interobserver reliability of the lateral capitellohumeral angle (LCHA) in children without evidence of fracture and compare them with those of BA. METHODS: Seventy-one sets of anteroposterior and lateral elbow radiographs were selected and stratified into 6-year age categories with equal number of males and females in each category. Five physicians performed 3 separate measurements of LCHA and BA on each film set. Statistical calculations were performed to determine mean, SD, measurement reliability, and differences between patients groups. RESULTS: The mean LCHA ±1 SD and BA ± 1 SD measurements were 50.8 ± 6 degrees and 71.5 ± 6.2 degrees, respectively, and did not vary significantly by age, side, or sex (P>0.05). The LCHA showed good intraobserver (correlation coefficient 0.67) and fair interobserver (0.37) reliability, whereas BA showed excellent intraobserver (0.86) and interobserver (0.80) reliability. The expected SD for repeated measurement of a radiograph by a single observer was 2.6 degrees for BA and 5.2 degrees for LCHA. CONCLUSIONS: The LCHA is a simple measurement to perform using digital tools. In normal elbows, the mean angle is 51 ± 6 degrees and does not vary by age, side, or sex. LCHA variability in normal elbow radiographs is similar to BA. Its reliability is inferior to BA, but improves with age. Sagittal angulation abnormality of at least 12 degrees (<39 or >63 degrees) is necessary to be confident that the change is not because of measurement error alone. Further research is needed to better define the relationship of sagittal plane angular deformity to clinical outcome. LEVEL OF EVIDENCE: Diagnostic study with poor reference standard, Level IV.