The Gartland typing is a common typing system for evaluating and guiding supracondylar humeral fractures in children with good reliability. Its history, application, reliability, and limitations are described in a recent issue of CLIN ORTHOP RELAT R and are presented below.
Supracondylar fractures of the humerus are the most common elbow injury in children. Because supracondylar fractures of the humerus are often associated with skeletal deformities and Volkmann’s contracture, they were called “misunderstood fractures” in the 1850s. In 1959, Gartland proposed a simple staging scheme for supracondylar fractures of the humerus and discussed their treatment.
The supracondylar fracture of the humerus occurs proximal to the articular surface of the distal humerus, and the fracture line may be transverse, oblique, or comminuted; Gartlnd described rotational and transverse deformities of the fracture, with the distal end of the fracture often displaced posteriorly (the extension type). Based on the degree of fracture displacement, he classified the supracondylar humeral fractures of the extension type into 3 types, type I: no displacement; type II: mild displacement; and type III: severe displacement. The flexion type of supracondylar humerus fracture should use a different typing.
Supracondylar fractures of the humerus are often misunderstood and treatment requires attention to reduce the occurrence of fracture malunion and Volkmann’s contracture. A nondisplaced supracondylar humerus fracture can be fixed in a cast without manipulation by rotating the forearm in a neutral position with the elbow flexed 75° to 80°. Emphasis is placed on the neurological and vascular system and on opposing tight plaster dressings and fixation of the elbow in an angle of flexion greater than 80°.
For mildly displaced fractures, closed reduction plaster fixation under general anesthesia is preferred. If x-rays 24 hours after the initial reduction procedure show a displaced fracture or secondary displacement, the fracture is considered unstable and requires over-the-top bone traction at the base of the ulna.
Severely displaced supracondylar fractures can also be treated as described above, but with an increased proportion of instability and neurovascular injury in this type of fracture, which can be fixed with incisional reduction stainless steel kerf pins.
The current recommendations of the American Academy of Orthopaedic Surgeons (AAOS) for the treatment of supracondylar humerus fractures in children are still based on the modified Gartland’s staging. type I fractures are fixed in a cast for 3 to 4 weeks with weekly follow-up X-rays for alignment of the fracture. type IIA fractures are fixed in a closed reduction cast or with percutaneous kerf pins, whereas type IIB fractures require closed reduction with percutaneous kerf pins to The IIA fracture is fixed with a closed reduction cast or percutaneous pinning, while the IIB fracture requires closed reduction percutaneous pinning to avoid coronal or other angular rotational deformities.
Type III and IV fractures also require closed reduction percutaneous pinning and can therefore be considered as types of fractures requiring fixation, with incisional internal fixation being considered when good reduction cannot be achieved with closed reduction.
The choice of access for an incisional reduction – lateral, medial or anterior – is considered on a case-by-case basis. The need for debridement and irrigation of open fractures, unsuccessful closed reduction for incisional surgery, and the absence of blood supply to the distal part of the fractured limb (no pulse, hand color other than pink) will determine the choice of access.
Suspension traction is rarely used in modern medicine and is only indicated in certain situations such as when anesthesia is not possible or the patient’s comorbidities do not allow for anesthesia, when there is no suitable surgeon available to perform the procedure, and when the limb is severely swollen and requires temporary braking.
Volkmann’s contracture deformity is considered a nightmare when treating supracondylar fractures of the humerus and is a complication of untreated forearm intercompartmental syndrome. Early treatment of elbow trauma, increased vigilance for the clinical and physiological manifestations of osteoinferior intercompartmental syndrome, and adequate and timely fasciotomy for decompression can reduce the occurrence of forearm contracture deformity.
However, the incidence of fascial compartment syndrome in patients with supracondylar humeral fractures remains between 0.1% and 0.3%. Although fascial compartment syndrome is more likely to occur in patients with high injury violence and a high degree of fracture displacement, it occurs in all patients with the Gartland fracture subtype.
Description of the Gartland fracture subtype
A Gartland extension type I injury is usually a nondisplaced transverse fracture. There may be widespread swelling of the elbow joint, but there is no evidence of nerve or vascular damage. An extension type II fracture is usually described as a “mildly displaced” or rotated fracture and usually requires repositioning. An extension (type III) fracture is usually an oblique fracture with severe displacement and rotation. When the fracture is more displaced, there is an increased risk of nerve or vascular injury.
Wilkins has refined the Gartland classification to be more clinically relevant by incorporating the concept of posterior cortical contact of the humerus. An extension type I injury is a fracture without displacement; a type II injury is a fracture in which the posterior humeral cortex is in contact but the fracture is displaced forward (the anterior fracture line is located anterior to the humeral tuberosity; see Figure 1); and a type III fracture is a displaced fracture without cortical contact. type IIA fractures have no rotational deformity or fracture displacement, whereas type IIB fractures have these conditions and are more unstable.
In 1995, De Boeck et al. described another subtype of supracondylar humeral fracture, namely, comminution and instability of the medial humeral column, resulting in reduction of the Baumann angle, and they recommended closed reduction percutaneous needle fixation for this type of fracture. In 2006, Leitch et al. suggested adding a subtype for type IV injuries, which are more difficult to treat due to multiplanar instability, intraoperative confirmation of instability only, and the absence of an intact periosteal hinge.
The Baumann angle is the angle formed by the intersection of the longitudinal extension of the humerus (A) with the oblique line of the lateral humeral epicondyle (B) in the anteroposterior position (normal range 64° to 81°), α= angle (translator’s note: the original image schematic is incorrectly labeled)
Lateral image diagram showing Gartland type I (A), II (B), and III (C) supracondylar fractures of the humerus.
Modified Gartland’s staging of supracondylar humerus fractures
I
Slightly displaced
Fat pad elevation on x-ray
II
Posterior cortical linkage
Anterior edge of humeral stem located anterior to the humeral tuberosity
III
Displacement
No cortical linkage
IV
Extension or flexion displacement
Imaging shows flexion or extension instability
Reduced medial Baumann angle
Comminution of the fracture end
Collapse of the medial humeral column
Limited
The Gartland staging does not specifically include complications of neurovascular injury in the staging, but vascular injury occurs almost exclusively in distal humeral fractures of extension type II or higher staging. The proximal end of the fracture in a supracondylar humeral fracture can be overtopped and severed, causing spasm or occlusion of the brachial artery, either before or after repositioning.
It has been reported in the literature that 7% to 12% of supracondylar humeral fractures have a loss of radial artery pulsation at the initial visit, but the occluded or tortuous artery can be restored after the fracture is adequately repositioned, and the incidence of vascular compromise after repositioning is less than 0.8%. The indication for brachial artery dissection is based on peripheral blood perfusion and not on the presence of a pulsatile pulse.
Nerve injury is currently considered to be the most common complication of supracondylar humeral fractures, with an incidence of 11.3%. Primary nerve injury is thought to be due to sharp fragments proximal to the fracture end or entrapment of the nerve at the fracture site. Some studies have shown that 86% to 100% of nerve injuries are functional paralysis and can resolve spontaneously.
Extension fractures are the most common type of fracture and pose a significant risk of injury to the anterior interosseous nerve. In extension fractures, the weighted incidence of traumatic nerve palsy is 11.3%, with anterior interosseous nerve palsy accounting for 34.1% of the total. The weighted incidence of traumatic nerve palsy in the less common flexion supracondylar humerus fracture was 16.6%, with ulnar nerve palsy accounting for 91.3% of the total.
The Gartland typing is a common typing system for evaluating and guiding supracondylar humerus fractures in children, with good inter- and intraobserver reliability of assessment. type III injuries are usually associated with neurovascular injury and require high priority. the results of Gartland’s work are the basis for modern treatment of supracondylar humerus fractures.