The effect of a new subtype classification system on prognosis and outcome analysis in pediatric extension-type Gartland type III distal humerus supracondylar fractures

Fracture morphology and multidirectional instability in failed closed reduction of pediatric supracondylar humerus fractures

Purpose: To evaluate clinical and fracture-related factors associated with failed closed reduction in high-risk pediatric supracondylar humerus fractures (SCHF), with emphasis on fracture morphology and intraoperative multidirectional instability. Methods: This retrospective cohort study included 318 consecutive children aged 2–12 years who underwent surgery for Gartland type III SCHF or intraoperatively confirmed Gartland type IV instability between 2015 and 2025. Fractures were classified as typical extension-type, medial oblique, lateral oblique, or flexion-type. Univariable and multivariable logistic regression analyses were performed. Results: Closed reduction was successful in 192 patients, whereas 126 required conversion to open reduction. Flexion-type fractures had the highest open reduction rate (80.0%; p < 0.001). In the full multivariable model, Gartland type IV instability was strongly associated with open reduction (odds ratio 5.21, 95% confidence interval 2.69 to 10.53; p < 0.001). Compared with flexion-type fractures, typical, medial oblique, and lateral oblique patterns had significantly lower adjusted odds. Older age and longer time from injury to surgery were also associated with open reduction. Conclusions: Flexion-type morphology and intraoperatively confirmed Gartland type IV instability were strongly associated with failed closed reduction. These findings may help surgeons anticipate reduction difficulty and plan operative resources in high-risk pediatric SCHF. Significance of Study: Recognizing fracture morphology and intraoperative multidirectional instability may help surgeons anticipate failed closed reduction in high-risk pediatric SCHF. Level of evidence: III

Multicenter validation of the modified wu classification as a 3d triplanar framework for proximal tibiofibular fractures

Accurate evaluation of proximal tibiofibular fractures remains clinically challenging. This study aimed to evaluate the diagnostic applicability and compare the inter-observer reliability and intra-observer reproducibility of the novel modified Wu classification (mWC) against three established systems (AO/OTA, Schatzker, and Luo). A multicenter, retrospective study was conducted analyzing 320 independent proximal tibiofibular fracture cases (comprising 171 cases in males and 149 cases in females; mean patient age, 45.76 ± 15.82 years) treated between January 2010 and October 2023. Four independent observers of varying clinical expertise evaluated plain radiographs, 2D CT, and 3D reconstructions to classify the fractures across the four systems. A second blinded assessment was performed following a four-week washout period. Agreement was quantified utilizing Fleiss’ kappa and Cohen’s kappa coefficients. Traditional systems failed to adequately categorize 26.9% (86/320) of cases, whereas the mWC successfully achieved a 100% classifiability rate. For inter-observer reliability, the mWC demonstrated substantial agreement (κ = 0.616), outperforming the Luo (κ = 0.597), Schatzker (κ = 0.484), and AO/OTA (κ = 0.449) classifications. Regarding intra-observer reproducibility, the mWC showed substantial agreement (mean κ = 0.772), which was statistically secondary to the almost perfect agreement achieved by the Luo system (κ = 0.831), but remained superior to the substantial agreement demonstrated by the Schatzker (κ = 0.700) and AO/OTA (κ = 0.696) systems. Crucially, the specific structural sub-components of the mWC (column, region, and segment) consistently yielded substantial to almost perfect agreement across evaluations.The mWC represents a structured evaluative framework that addresses several morphological gaps of traditional systems for evaluating proximal tibiofibular fractures. By integrating 3D anatomical precision and effectively addressing complex fracture patterns with concomitant fibular involvement, the mWC provides a consistent, reproducible framework that expands taxonomic classifiability, potentially facilitates preoperative surgical planning, and supports the standardization of future clinical research.

Do surgical technique and pin configuration influence clinical and radiological outcomes in pediatric supracondylar humerus fractures? a modified Flynn-based analysis.

A Prospective Study on Clinical and Functional Outcome of Surgical Management Of supracondylar Fracture of Humerus in Children with Cross K -Wire Fixation

Background: Displaced supracondylar humeral fractures are common paediatric elbow injuries and may cause malunion, neurovascular complications, stiffness, and functional impairment. This study evaluated the clinical, radiological, and functional outcomes and complications of crossed percutaneous K-wire fixation following closed reduction. Methods: A prospective study was conducted in 50 children younger than 12 years with displaced supracondylar humeral fractures. Patients with open fractures, vascular injury, malunion, or age >12 years were excluded. Fractures were classified using the modified Gartland classification. Clinical and radiological outcomes were assessed using elbow range of motion, carrying angle, Baumann’s angle, fracture alignment, and complications. Functional outcomes were graded using Flynn’s criteria at 4, 12, and 24 weeks. Results: The study included 39 males (78%) and 11 females (22%), with a mean age of 7.12 ± 2.30 years. The left elbow was involved in 66%, and extension-type fractures accounted for 96%. Posteromedial displacement was most common (48%). Two K-wires were used in 56% and three in 44%. At follow-up, 74% had ≤5° loss of elbow motion, with a mean loss of 3.62 ± 3.68°. Loss of carrying angle was ≤5° in 86%, with a mean loss of 3.04 ± 2.96°. Flynn grading showed excellent outcomes in 86%, good in 10%, fair in 2%, and poor in 2%, giving 96% satisfactory results. Superficial pin-tract infection and movement restriction occurred in 14% each, while iatrogenic ulnar nerve palsy occurred in 4% and K-wire migration in 2%. Conclusion: Crossed percutaneous K-wire fixation following closed reduction provides stable fixation and favourable clinical, cosmetic, and functional outcomes in appropriately selected children, although careful medial pin placement is essential to minimize ulnar nerve injury.

[A special type of triple injury of superior shoulder suspensory complex-lateral segment floating clavicle].

Coronal shear fractures of the distal humerus in children and adolescents: proposal for a modified classification

Coronal shear fractures (CSF) of the capitulum and trochlea humeri are rare injuries during growth age. No systematic, prospective analysis of the classification, procedure, and outcome has yet been found in the literature. Based on the results of a multicentre study of CSF in growing patients, we propose a redesign of the AO Paediatric Comprehensive Classification of Long-Bone Fractures (PCCF) for children and adolescents. We also assessed inter-rater agreement consistency with the modified classification and calculated the intra-class correlation coefficient (ICC) and its 95% confident interval (CI). A detailed classification has been proposed that refers to the location of the fragment, the extent to which the trochlea is involved, and the distinction between single and multiple fracture injuries. This modified AO classification distinguishes between five types of injury (13-E/3.1I – 13-E/3.1IV and 13-E/3.2), replacing the current code 13r-E/8.1. Inter-rater reliability using this modified classification was moderate (ICC 0.452 (95% CI 0,284; 0,661). This is more accurate than all previous classifications tested for CSF. A revised classification of coronal shear fractures of the distal humerus in children and adolescents is required. Our proposed classification considers the various types of this injury and their implications for treatment. Cross-sectional imaging is necessary for any classification to be applied successfully, since plain radiographs do not provide sufficiently precise information.