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Three Part Question

In [children with supracondylar humeral fractures], is [the modified Gartland Classification System] reliable in [decision for admission and operative management]?

Clinical Scenario

A 4 year old girl attends your accident and emergency department crying and unable to move her left elbow after a fall on outstretched hand at school. You identify a Gartland Type IIa fracture on the plain radiograph. You wonder if admission is necessary for her angulated fracture.

Search Strategy

National Library of Medicine 2006-2024 using the OVID interface.

({Gartland operative decision} LIMIT to human AND english.

Search Outcome

23 papers were found in total of which 3 were relevant. They are shown in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Leung S, Paryavi E, Herman MJ, Sponseller PD, Abzug JM. Does the Modified Gartland Classification Cl 2018 USA	200 anteroposterior and lateral radiographs of pediatric supracondylar humerus fractures were retrospectively reviewed by 3 fellowship-trained pediatric orthopaedic surgeons and 2 orthopaedic residents and then classified as type I, IIa, IIb, or III. The surgeons then recorded whether they would treat the fracture nonoperatively or operatively.	Retrospective	Decision to operate	For fractures classified as type I, the decision to operate was made 3% of the time. If classified as type IIa (no malrotation or translation), the decision to operate was made 27% of the time, and 99% of the time if classified as type IIb (malrotation and/or translation). The decision was made to operate for 100% of fractures classified as type III	Our low reliability rates for type II fractures, however, imply that there is difficulty in detecting rotational and translational deformities that are often subtle in fractures in which the posterior cortex remains intact. Baumann’s angle, the angle between the long axis of humeral shaft and the lateral condyle physis, has been shown to be useful in determining resultant carrying angle after reduction.17 Therefore, it can also be useful in assessing for the presence of rotational malalignment. With a low interobserver rating for type II fractures, the classification as a treatment guide has low utility.
Tangadulrat, Pasina,b; Adulkasem, Natha; Suganjanasate, Kuntaleea; Wongcharoenwatana, Jidapaa; Ariya 2023 Thailand	An online questionnaire was developed and sent to the Thai Paediatric Orthopedics Society and Asia-Pacific Paediatric Orthopaedic Society members. The results were analyzed to explore the relationship between respondents’ demographic factors and treatment decisions. Out of 113 participants reached, 57 (50.4%) responded to the questionnaire.	Questionnaire of Expert Opinion	Type II subclassification is necessary for determining operative treatment	33 of 57 respondents (57.9%) deemed subclassification for Gartland type II necessary for guiding treatment.	Lowest level of evidence (Expert Opinion). Subjective, no patient or radiograph evaluated
Teo TL, Schaeffer EK, Habib E, El-Hawary R, Larouche P, Shore B, Aarvold A, Carsen S, Reilly C, Mulp 2020 USA	Anteroposterior and lateral elbow radiographs from 60 paediatric patients with extension-type supracondylar humerus fractures were compiled. After classifying each fracture according to Gartland classification guidelines, radiographs were randomized, and 11 surgeons indicated whether they would use operative or non-operative management to treat each fracture.	Retrospective Cohort Study	Management decision	The largest variability in preferred treatment methods between surgeons was observed for type IIA fractures, with 6/11 preferring non-operative and 5/11 preferring operative management. The largest individual surgeon variability was observed for type IIA fractures, with 8/11 showing variability (defined by not having made the same decision for at least 90% of the cases) in choosing whether to operate.

Comment(s)

All studies showed definite reliability of Gartland Type I and III to deciding management, but much inter-observer variability for Type IIa and IIb fractures, especially IIa. This suggests that there are radiographic features other than rotation and translation that predict neurovascular complication.

Clinical Bottom Line

Orthopaedic surgeons usually agreed on what X-ray findings indicated surgical management, although those radiographic features may not be fully represented by the Modified Gartland Classification alone. A more definitive guideline with these yet to be identified features could be formulated to guide initial management in AED.

References

1. Leung S, Paryavi E, Herman MJ, Sponseller PD, Abzug JM. Does the Modified Gartland Classification Clarify Decision Making? J Pediatr Orthop. 2018 Jan;38(1):22-26. doi: 10.1097/BPO.0000000000000741. PM Does the Modified Gartland Classification Clarify Decision Making?
2. Tangadulrat, Pasina,b; Adulkasem, Natha; Suganjanasate, Kuntaleea; Wongcharoenwatana, Jidapaa; Ariya Is subclassification of Gartland extension-type pediatric supracondylar fracture into types IIA and IIB necessary for treatment decision? A result of pediatric orthopedist’s survey and review of liter
3. Teo TL, Schaeffer EK, Habib E, El-Hawary R, Larouche P, Shore B, Aarvold A, Carsen S, Reilly C, Mulpuri K. Is the modified Gartland classification system important in deciding the need for operative management