Assessing the reliability of the modified Gartland classification system for extension-type supracondylar humerus fractures

Abstract

PurposeThe Gartland extension-type supracondylar humerus (SCH) fracture is the most common paediatric elbow fracture. Treatment options range from nonoperative treatment (taping or casting) to operative treatments (closed reduction and percutaneous pinning or open reduction). Classification variability between surgeons is a potential contributing factor to existing controversy over treatment options for type II SCH fractures. This study investigated levels of agreement in extension-type SCH fracture classification using the modified Gartland classification system.MethodsA retrospective review was conducted on 60 patients aged between two and 12 years who had sustained an extension-type SCH fracture and received operative or nonoperative treatment at a tertiary children’s hospital. Baseline radiographs were provided, and surgeons were asked to classify the fractures as type I, IIA, IIB or III according to the modified Gartland classification. Respondents were then asked to complete a second round of classifications using reshuffled radiographs. Weighted kappa values were calculated to assess interobserver and intraobserver levels of agreement.ResultsIn all, 21 paediatric orthopaedic surgeons responded to the survey and 15 completed a second round of ratings. Interobserver agreement for classification based on the Gartland criteria between surgeons was substantial with a kappa of 0.679 (95% confidence interval (CI) 0.501 to 0.873). Intraobserver agreement was substantial with a kappa of 0.796, (95% CI 0.628 to 0.864)ConclusionRadiographic classification of extension-type SCH fractures demonstrated substantial agreement both between and within surgeon raters. Therefore, classification variability may not be a major contributing factor to the treatment controversy for type II SCH fractures and treatment variability may be due to differences in surgeon preferences.Level of EvidenceIII

Recommendations for the Care of Pediatric Orthopaedic Patients During the COVID-19 Pandemic

“…S ince the first case of the novel coronavirus (COVID- 19) was reported in Wuhan, China in December 2019, viral infection has spread at an alarming rate. On January 30, 2020, the World Health Organization (WHO) announced COVID-19 as a Public Health Emergency of International Concern, and by March 11, 2020, it was officially declared a pandemic.…”

“…continued )Recommendations for Orthopaedic Pediatric Elective Management19,20 Significant change in usual management in the setting of COVID.…”

Is the modified Gartland classification system important in deciding the need for operative management of supracondylar humerus fractures?

“…This is the second phase of the study previously described. 8 The first phase investigated levels of agreement between surgeon respondents in fracture type classification using the modified Gartland classification system. After Institutional Research Ethics Board approval was obtained, we retrospectively reviewed the radiographs and charts of all patients from two years to 12 years of age who had been treated for an extension-type supracondylar humerus fracture at our institution from 1st January 2005 to 31st December 2016.…”

“…[5][6][7] We previously sought to investigate whether differences between surgeons in treatment preferences for type II fractures are due to surgeons classifying the same types of fractures differently. 8 Substantial overall levels of agreement were found between surgeon respondents in the classification of fractures using the modified Gartland criteria, suggesting that variability in classification may not be a significant contributor to the current treatment controversy for type IIA fractures. If the controversy over treatment cannot be explained by variability in classification, then there is a need to identify where the differences in practice patterns lie and the factors underlying these differences, with particular regard to the role of the modified Gartland classification system in the treatment decision-making process.…”

Overview of the contemporary management of supracondylar humeral fractures in children

“…Wilkins extended this to include the concept of posterior humeral cortical contact with a rotational deformity, suggested by translation, visible in either plane [18]. Fractures were subdivided into IIa: posterior hinge intact without rotation and IIb: posterior hinge intact with rotation and this modification has good intra-and inter-observer reliability [19][20][21][22].…”