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This study evaluated the reproducibility of the Gartland classification system for supracondylar humeral fractures in children. Radiographs of 50 fractures in children were classified by 4 orthopedic surgeons on two occasions according to the Gartland system. There was moderate agreement between surgeons except for type 1 fractures. Intra-observer agreement was good to very good, but inter-observer agreement was only moderate. The study concludes the Gartland classification shows limited reproducibility between surgeons and that fractures should be treated based on the degree of displacement rather than the classification.

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This study evaluated the reproducibility of the Gartland classification system for supracondylar humeral fractures in children. Radiographs of 50 fractures in children were classified by 4 orthopedic surgeons on two occasions according to the Gartland system. There was moderate agreement between surgeons except for type 1 fractures. Intra-observer agreement was good to very good, but inter-observer agreement was only moderate. The study concludes the Gartland classification shows limited reproducibility between surgeons and that fractures should be treated based on the degree of displacement rather than the classification.

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Iqbal Baryar
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Journal of Orthopaedic Surgery 2007;15(1):12-4

Reproducibility of the Gartland classification


for supracondylar humeral fractures in
children
J Heal

Avon Orthopaedic Centre, Southmead Hospital, Bristol, United Kingdom

M Bould

Department of Orthopaedic Surgery, Weston General Hospital, Weston-super-Mare, United Kingdom

J Livingstone

Department of Orthopaedic Surgery, Bristol Royal Infirmary, Bristol, United Kingdom

N Blewitt, AW Blom

Frenchay Hospital, Bristol, United Kingdom

ABSTRACT
Purpose. To evaluate the intra- and inter-observer
reproducibility of the Gartland radiographic classification for supracondylar humeral fractures in
children.
Methods. Anteroposterior and lateral radiographs of
50 supracondylar humeral fractures in children were
graded on 2 separate occasions by 4 orthopaedic
surgeons according to the Wilkins modification of
the Gartland classification. Data were analysed by
calculating the Kappa values for intra- and interobserver agreement to indicate the reproducibility of
the classification.
Results. There was moderate inter-observer agreement, except for poor agreement over type I fractures.
Type II fractures only showed fair to moderate
agreement. Type III fractures and the flexion group

showed good to very good agreement. Intra-observer


agreement was good to very good.
Conclusion. Surgeons should treat paediatric supracondylar humeral fractures based on an assessment of
the degree of displacement rather than by employing
the Gartland classification.
Key words: humeral fractures; observer variation;
reproducibility of results

INTRODUCTION
In 1959 Gartland1 noted the trepidation with
which men, otherwise versed in the management of
trauma, approach a fresh supracondylar fracture.
Supracondylar fractures of the humerus are notoriously difficult to treat and are the second most
common fractures in children,2 and the most
common around the elbow.3,4 They are divided into

Address correspondence and reprint requests to: Mr Ashley W Blom, 23 Old Sneed Ave, Stoke Bishop, Bristol, BS9 ISD, United
Kingdom. E-mail: blocat@msn.com

Vol. 15 No. 1, April 2007

Reproducibility of the Gartland classification for supracondylar humeral fractures in children

Table 1
Interpretation of Kappa
Kappa
0.20
0.210.40
0.410.60
0.610.80
0.811.00

13

Table 2
Intra-observer agreement

Strength of agreement

Observer

No. of radiographs

Kappa

1
2
3
4

50
50
48
48

0.83
0.82
0.68
0.75

Poor
Fair
Moderate
Good
Very good

Table 3
Inter-observer agreement
No. of radiographs

48

Combined Kappa

0.54

Kappa by category of Wilkins modification of the Gartland classification


Type 1

Type 2A

Type 2B

Type 3

Type 3 flexion

0.13

0.43

0.36

0.76

0.85

either extension (9598%) or flexion type (25%).5


The first radiological classification system for such
fractures was proposed by Felsenreich6 in 1931
according to the degree of displacement; however,
this is generally accredited to Gartland. Wilkins79
modified the Gartland classification but maintained
the basis of the 3 types: Type I where the fracture
is undisplaced or minimally displaced, such that
the anterior humeral line still passes through the
ossification centre of the capitellum. Type II where
there is an obvious fracture line with displacement of
the distal fragment, but there is still an intact cortex
posteriorly. The direction of the displacement may
be straight posteriorly, or angulated medially or
laterally and there may be a rotary component. Type
III where the fracture is displaced with no cortical
contact with either posteromedial or posterolateral
displacement. Wilkins subdivided type III fractures
(often misquoted as type II) into A and B, depending
on the absence or presence of rotation. For the
purpose of clarity and convention, we subdivided
Wilkins type II fractures into A (without rotation)
and B (with rotation). Some also classify according to
the degree of displacement,10 while others base it on
the site and direction of the fracture line.11
The management of these fractures remains
controversial. Gartland originally recommended that
type I fractures be immobilised in a splint with the
elbow flexed to 75 to 80. Type II and stable type III
fractures require manipulation under anaesthesia and
then immobilisation as for type I fractures. Unstable

type III fractures are managed with skeletal traction


with a Kirschner wire through the ulna distal to the
olecranon tip. Other methods of internal fixation
include bone pegs, Kirschner wires,12 and periosteal
stitches. A protocol for management 13 based on
the Wilkins classification suggests that minimally
displaced fractures without rotation (type I and IIA)
are managed with manipulation under anaesthesia
and plaster. When there is a rotational deformity or
no posterior cortical contact (type IIB and III), the
fractures are managed with reduction and fixation
with 2 crossed 1.6-mm Kirschner wires.
We have noticed considerable disagreement
between orthopaedic surgeons on the classification
of these fractures and management, particularly
with regard to the presence or absence of rotational
deformity. The rotation does not result in a varus
deformity directly, but predisposes to tilt or angulation of the distal fragment, which produces a varus
or valgus deformity.14 The rotation can be reduced
and fixed by Kirschner wires. Our null hypothesis
was that the Wilkins modification of the Gartland
classification was reproducible.
MATERIALS AND METHODS
Anteroposterior and lateral radiographs of 50 supracondylar humeral fractures in children were graded
on 2 separate occasions by 4 orthopaedic surgeons
according to the Wilkins modification of the Gartland

14

Journal of Orthopaedic Surgery

J Heal et al.

classification, with subdivision of type II fractures


into A and B.
Data were analysed by calculating the Kappa
values for intra- and inter-observer agreement to
indicate the reproducibility of the classification. Kappa
represents the proportion of agreement beyond that
expected by chance; a kappa of one represents perfect
agreement and 0 represents no more agreement
than would be expected by chance; a kappa of <0
represents less agreement than would be expected by
chance (Table 1).
RESULTS
Tables 2 and 3 show the extent of intra- and interobserver agreement. Overall there was a moderate
inter-observer agreement, except for poor agreement
over type I fractures. Type II fractures only showed
fair to moderate agreement. Type III fractures and the
flexion group showed good to very good agreement.
Intra-observer agreement was good to very good.

DISCUSSION
Supracondylar humeral fractures in children
are common and treatment is based on their
radiographic classification. Displacement with
rotation is an indication for Kirschner-wire fixation.13
The presence of rotation does not directly result in
an alteration in the carrying angle and therefore
deformity; it does however predispose to tilt and
induce cubitus varus/valgus.4 This is particularly
important as anteroposterior displacement will
remodel in children, but a rotational deformity
will not. Cubitus varus/valgus is a cosmetic
deformity causing minimal functional deficit, but
it is difficult to correct and has a high complication
rate of 33%.5
The null hypothesis in this study has been
disproved; inter-observer agreement was only
moderate. Surgeons should treat supracondylar
humeral fractures based on the assessment of the
degree of displacement rather than by employing the
Gartland classification.

REFERENCES
1. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 1959;109:14554.
2. Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma
1993;7:1522.
3. Blount WP. Fractures in children. Baltimore: Williams and Wilkins; 1955:2637.
4. Smith FM. Childrens elbow injuries: fractures and dislocations. Clin Orthop Relat Res 1967;50:730.
5. Labelle H, Bunnell WP, Duhaime M, Poitras B. Cubitus varus deformity following supracondylar fractures of the humerus
in children. J Pediatr Orthop 1982;2:53946.
6. Felsenreich F. Kindliche supracondylaive fracturen und posttraumatisch deformotaten des ellenbogen gelenhes [in German].
Arch Orthop Unfall-Chir 1931;29:5559.
7. Wikins KE. The operative management of supracondylar fractures. Orthop Clin North Am 1990;21:26989.
8. Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE, King RE, editors. Fractures in
children. Vol III, 3rd ed. Philadelphia: JB Lippincott; 1984:5401.
9. Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE, King RE, editors. Fractures in
children. Vol III, 4th ed. Philadelphia: JB Lippincott; 1984:6801.
10. Flynn JC. Zink WP. Fractures and dislocations of the elbow. In: MacEwen GD, Kasser JR, Heinrich SD, editors. Pediatric
fractures a practical approach to assessment and treatment. Baltimore: Williams and Wilkins; 1993:13364.
11. el-Ahwany MD. Supracondylar fractures of the humerus in children with a note on the surgical correction of late cubitus
varus. Injury 1974;6:4556.
12. Swenson AL. The treatment of supracondylar fractures of the humerus by Kirschner wire transfixation. J Bone Joint Surg Am
1948;30:9937.
13. OHara LJ, Barlow JW, Clarke NM. Displaced supracondylar fractures of the humerus in children. Audit changes practice.
J Bone Joint Surg Br 2000;82:20410.
14. Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. Sixteen
years experience with long-term follow-up. J Bone Joint Surg Am 1974;56:26372.

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