Gartland Classification

What is a supracondylar fracture?

A supracondylar humeral fracture, also known as, particularly common as pediatric supracondylar humerus fractures, is a type of break in the bone that affects the distal humerus, just above the elbow joint. It involves the distal (lower) end of the humerus, the long bone in the upper arm. This fracture is most common in children, especially those under the age of 10, due to other fractures of the humerus and vulnerability of this area during falls or direct impacts.

Causes

The primary cause of a supracondylar fracture is trauma, often resulting from a fall with an outstretched hand or a direct blow to the elbow. In children, the relatively weaker bones and their tendency to engage in physical activities make them more susceptible to this kind of injury.

Symptoms

The symptoms of a supracondylar fracture include:

• Severe pain in the elbow area, and in some cases, median nerve injury
• Swelling and tenderness around the elbow
• Visible deformity, especially if the bone fragments are displaced
• Restricted movement in the arm
• Numbness or weakness in the hand, in severe cases involving nerve damage
• In severe cases, symptoms may include issues related to the anterior interosseous nerve, affecting thumb and finger flexion

What is the Gartland Classification system?

The Gartland Classification system is a method used to categorize the severity of extension type fractures in the supracondylar humerus at the elbow based on sagittal plane displacement. This classification categorizes the severity of displaced supracondylar fractures and is crucial as it helps guide the treatment approach and predict potential complications. The system divides the fractures into three main types based on the degree of displacement of the bone fragments.

Type I

Type I fractures are considered non-displaced, meaning the bone remains aligned correctly despite the fracture. These fractures may not be easily visible on X-rays and typically require conservative treatment, such as immobilization with a cast.

Type II

Type II fractures involve partial displacement of the bone, where a hinge is still intact. This means that while part of the bone has shifted, another segment remains in place, maintaining some connection.  In Type II injuries, the displacement may still allow the anterior humeral line to intersect part of the capitellum, unlike in more severe displacements. However, this type can already lead to sagittal plane deformity, as well as the more severe types. Treatment often involves immobilization and may require manipulation under anesthesia to realign the bone.

Type III

Type III fractures, being completely displaced, carry a higher risk of complications such as ulnar nerve palsy and ulnar nerve injury. They are the most severe and require surgical intervention to realign and stabilize the bone fragments, often using pins or other hardware. The risk of complications, including nerve and vascular injury, is higher with Type III fractures. Type II and Type III are considered displaced supracondylar fractures, requiring more intensive intervention. Type III can lead to worse issues like coronal plane deformity or compartment syndrome.

Type IV

Initially not part of the original Gartland classification, Type IV fractures were later added to account for pediatric supracondylar humeral fractures that exhibit greater instability. Type IV fractures are characterized by complete displacement with no cortical contact and disruption of the periosteal hinge, leading to multidirectional instability. This means that the fracture is unstable in both flexion and extension, unlike the other Gartland types (I-III), which maintain some degree of cortical contact or an intact posterior hinge, making them more stable. Type IV fractures require more extensive surgical treatment, such as open reduction and percutaneous pinning, compared to the other Gartland types, which may be amenable to closed reduction and pinning. Like Type III, Type IV can lead to coronal plane malalignment and compartment syndrome.

How does our Gartland Classification template work?

The Gartland Classification template provides a detailed and structured approach to categorizing supracondylar humerus fractures, which is crucial for diagnosing and planning the treatment strategy. Here’s how it functions:

• Detailed fracture descriptions and diagrams: The template categorizes fractures into four main types based on the degree of displacement and the condition of the bone cortex. Each type is further subdivided to provide a more precise understanding of each type's characteristics.
• Guidance for clinical assessment: By defining the characteristics of each fracture type, the template aids clinicians in quickly identifying the specific category of a supracondylar fracture. This initial classification is essential for determining the appropriate treatment pathway.
• Standardizing communication: The classification helps maintain consistency in how fractures are described among healthcare providers, improving the clarity and efficiency of communication within clinical teams and across medical documentation.

How will healthcare professionals benefit from our template?

Healthcare professionals will benefit from the Gartland Classification template, which provides a systematic and precise method for assessing supracondylar humerus fractures, crucial for formulating an effective treatment plan. By clearly defining the extent of displacement and cortical integrity across different fracture types, the template aids in accurately diagnosing and classifying injuries.

This clarity allows clinicians to choose the most appropriate treatment strategy, whether it involves conservative management or surgical intervention, based on the specific characteristics of the fracture site.

Additionally, this standardized classification enhances communication among medical team members and patients about treatment options and expected outcomes. It also contributes to the consistency of medical documentation and research, facilitating the aggregation and analysis of data across studies or clinical settings.

Treatments for supracondylar fractures

Treating supracondylar fractures depends on their type and severity, as the Gartland classification system categorizes them. The primary goal is to ensure proper bone alignment for effective healing and to minimize the risk of complications.

Non-surgical treatment

Non-surgical treatments are typically used for Type I fractures and some Type II fractures that can be realigned without surgery:

• Casting: Immobilizing the arm in a cast keeps the bone in proper alignment as it heals.
• Splinting: Using a splint to provide support and limit movement, allowing swelling to decrease before casting.
• Closed reduction: Manually adjusting the bone to its original position under anesthesia, followed by immobilization.

Surgical treatment

Surgical treatments are generally required for Type III fractures and some Type II fractures that cannot be properly aligned without surgery:

• Open reduction and internal fixation (ORIF): Surgically exposing the fracture to realign the bone fragments and securing them with pins, screws, or plates.
• Closed reduction and percutaneous pinning: Aligning the bones through manual manipulation under anesthesia and then inserting pins to hold the bone fragments in place without a large incision.

Rehabilitation

Rehabilitation is a crucial component of treatment for all types of supracondylar fractures, involving:

• Physical therapy: Exercises to restore joint mobility, muscle strength, and overall function of the arm.
• Occupational therapy: Techniques to assist patients in returning to their daily activities and adapting to any temporary limitations.