Classification Of Long Bone Fractures Research Articles

Treatment outcomes analysis in supracondylar humerus fractures in children and adolescents

Background. Distal epimetaphyseal humerus fractures in children and adolescents are relatively common injuries, with supracondylar and transcondylar fractures being the most prevalent. Among injuries to the distal humerus, these fractures occur most frequently and are one of the most common household injuries, composing 47.5–80 % of all intra-articular fractures of the elbow in children aged 3–12 years. Poor treatment outcomes range from 6.67 to 18.2 %. The aim is to study a current stage and therapeutic challenges in supracondylar humerus fractures in children and adolescents, and to find out optimal management based on analysis of the long-term treatment outcomes in this category of patients. Materials and methods. A retrospective study of treatment outcomes was conducted in 123 patients with supracondylar humerus fractures in 2019–2021. Average age of patients was 7.38 ± 0.34 years. Targeted clinical and instrumental examination have been performed in all patients. Fracture type was assessed based on AO Pediatric Comprehensive Classification of Long-Bone Fractures (PCCF). Mayo Elbow Performance Score was used to evaluate treatment outcomes. Results. Determining the type of supracondylar humerus fractures using AO PCCF compared to Gartland classification is justified as it allows for a more detailed assessment of the injury, thereby expanding the possibilities for developing individualized treatment strategies. Poor treatment outcomes with reduction + external immobilization constitute 3.7 % of cases, closed reduction + percutaneous fixation + external immobilization — 6.1 %, open reduction + pin fixation + external immobilization — 8.8 %. Conclusions. Supracondylar fractures are one of the most frequent injuries to the distal humerus and mostly occur in boys aged 4 to 9 years (58.3 % of cases). Fractures type II.1 (boys/girls ratio is 33.3/37.3 %) and III.1 (23.7/27.6 %) are dominating. Deepening the knowledge through anatomical and biomechanical studies of the structures with crossed and coronal pins will improve the existing fixation devices and will become the basis for the development of new ones, which will significantly improve treatment outcomes in supracondylar humerus fractures in children and adolescents.

Radial head and neck fractures in children and adolescents.

Radial head and neck fractures are a rare entity in pediatric patients. Due to specific characteristics of the blood supply and remodeling potential, the correct diagnosis and initiation of appropriate therapy are crucial for the outcome. Therefore, the aim of this retrospective observational study was to present the outcome of a series of pediatric patients with radial head and neck fractures. In total, 67 pediatric and adolescent patients with a fracture of the proximal radius admitted to a Level I Trauma Center (Germany) between 2005 and 2017 were included in this retrospective observational study. Patients were stratified in accordance with the classification of Judet modified by Metaizeau and with the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO-PCCF). AO-PCCF fracture type of proximal radius was age-dependent. Epiphyseal axis angle and displacement angle correlated significantly. Fractures treated with a K-wire or embrochage centromedullaire elastique stable (ECMES) presented higher displacement angles. The duration of callus formation was dependent on both the reduction technique and fracture displacement. The range of motion after complete fracture consolidation was dependent on the Metaizeau type and reduction technique but independent of the duration of immobilization and physical therapy. Both the epiphyseal axis and displacement angle are suitable for measuring the initial fracture displacement in radiographs. Consolidation is dependent on the initial displacement and reduction technique. The mini-open approach leads to a worse reduction result, later callus formation, and a more restricted range of motion in terms of pronation. Furthermore, the range of motion at follow-up is independent of the duration of immobilization and physiotherapy.

Diaphyseal Femur Fractures in Children and Adolescents-Opportunities and Limitations of the ESIN Technique.

Background: Elastic stable intramedullary nailing (ESIN) is the gold standard for non-overweight children aged 6−12 years. However, the complication rate using elastic stable intramedullary nailing is considerably high. Nevertheless, the question arises of whether the indication for elastic stable intramedullary nailing therapy can be extended and which factors must be taken into account when determining the indication. Methods: A retrospective chart review of patients <18 years admitted with diaphyseal femur fracture at a Level I Trauma Center in Germany between 2005 and 2017 was performed. In total, 118 patients were included. For the classification of femur fractures in children, the AO Pediatric Comprehensive Classification of Long-Bone Fractures (AO-PCCF) was applied. Results: Simple oblique fractures (32-D/5.1) occurred in most of the patients. Patients with simple oblique fractures were significantly younger compared to patients with simple transverse (32-D/4.1) or multifragmentary (32-D/5.2) fracture type according to the AO Pediatric Comprehensive Classification of Long-Bone Fractures. Most patients were treated with elastic stable intramedullary nailing (68 patients, 58%). Although children treated with elastic stable intramedullary nailing were older than those treated conservatively (25%, n = 29, mean age 1.5, median age 1.0), the children in the elastic stable intramedullary nailing group were comparatively young (range 1−12 years, mean age 5.4, median age 5). A total of 32 children below the age of 6 years were treated with elastic stable intramedullary nailing. Complications were more frequent in patients with overhead extension (50%) compared to conservative treatment with a spica cast (17%) or elastic stable intramedullary nailing (15%). Conclusions: Elastic stable intramedullary nailing therapy was associated with a low complication rate and was, therefore, a safe and frequently used treatment strategy in diaphyseal femur fractures with satisfactory results, even though the age groups were expanded in favor of younger patients.

Incidence, Occurrence and Classification of Long Bone Fractures in Dogs: A Retrospective Study

Background: Long bone fracture in small animals has become a problem of concern in urban areas as well as rural areas because of road accidents. Canine long bone fracture cases presented at surgery wards of the hospital during 2017-20 were analysed for determining their incidence, occurrence and classification of fractures. Methods: The present study was conducted on long bone fractures in dogs presented to the surgery ward of SVVU Super Speciality Veterinary Hospital, Visakhapatnam from 2017 to 2020. Detailed history and signalment was followed by detailed physical examination to determine the site of fracture, extent of soft tissue swelling and presence of open wounds. Radiographic evaluation was done to localize the seat of fracture, to identify the type of fracture and to find out relation between the fracture fragments Result: Of all the cases of dog patients presented to the surgery ward 2.02% were diagnosed to have fracture of different bones. Fracture of long bones (326), comprised 1.50% of total cases and 74.42% of fractures cases. The highest incidence was recorded in mongrel dogs and the most common affected bone was tibia fibula. Fall from height was reported as an etiological factor in majority of the cases and Juvenile group of animals was found more affected.

Some new directions in the treatment of fractures of long bones and their consequences

Elaborated biomechanical classification of long bone fractures and biomechanical conception of fragments fixation are showed to allow the choice of both the fixation mode and the type of fixatives for every specific case. Essentially new splint for the traction is presented. System (set of fixatives) for transosseous osteosynthesis providing stable joining of the plate and the screw is suggested. New device (III variant) for mono- and poly polar fixation of bone fragments using pins, rods and their combinations is created. It is possible to perform the fragments reduction in all directions of three- dimensional space.

Lower Leg Fractures in Children and Adolescents-Comparison of Conservative vs. ECMES Treatment.

Background: Lower leg fractures are one of the most common fractures in pediatric age. In general, treatment of lower leg fractures is predominantly non-operative, requiring clinical and radiological controls. Nevertheless, it can be observed that in recent years tibial shaft fractures have increasingly been treated surgically. The aim of the present study is to investigate treatment strategies in the context of different fracture types of the lower leg.Methods: In this retrospective chart review, we analyzed 168 children with a diaphyseal fracture of the lower leg admitted to a trauma center between 2005 and 2017. The fractures were classified according to the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO-PCCF).Results: The frequency of fractures based on the AO-PCCF classification was as follows: Simple oblique fracture of the tibia (43.5%, n = 73), hereof 32 toddler's fractures, multifragmentary oblique fracture of the tibia in 14.3% (n = 24) and simple oblique fracture of both, tibia and fibula in 18 patients (10.7%). Most pediatric fractures were treated conservatively by cast (n = 125). Thirty-seven patients received an ECMES, whereas 3 patients were treated with an external fixator and also 3 fractures were stabilized by plate osteosynthesis. Conservatively treated patients were significantly younger (mean age 6.0) compared to patients treated with ECMES (mean age 10.2) or plate osteosynthesis (PO)/external fixator (EF) (mean age 11.3), even if toddler's fractures (mean age 2.0) are excluded (mean age 7.4). There was no difference in time to full weight-bearing, hospitalization of patients treated with ECMES compared to conservative therapy although ECMES-treated fractures show more instability. The consolidation time was significantly higher in ECMES treated patients compared to conservative therapy.Conclusion: Pediatric patients (≤4 years) with lower leg fractures most often showed simple oblique fractures of the tibia, half of them toddler's fractures, which were treated predominantly by conservative therapy. All in all, the consolidation time was longer in intramedullary nailing (ECMES) than in conservative therapy. Nevertheless, time to full weight bearing and duration of cast was the same in both groups, even though ECMES treated fractures show more instability.

Risk factors for refracture of the femoral shaft in children after removal of external fixation

BackgroundExternal fixation is the primary treatment option in children for femoral shaft fractures, such as open femoral or multiple fractures. One complication is refracture, which is the biggest limitation of fixation devices. This study aims to investigate the risk factors associated with refracture after the removal of external fixation devices and decrease the frequency of refracture.Materials and methodsRetrospectively reviewed clinical data of 165 patients treated at our hospital for fresh femoral shaft fractures with external fixation between May 2009 and February 2018 were included in this study. Patients with pathological fractures, fractures of the femoral neck, fractures that were fixed using plates or elastic stable intramedullary nailing, and old fractures, as well as those who underwent postoperative femoral surgery were excluded. Potential risk factors included: patient age, gender, and weight, fracture sides, open or closed fracture, fracture sites, reduction methods, operation time, perioperative bleeding, number and diameter of the screws, and immobilization time. These factors were identified by univariate and logistic regression analyses.ResultsFemoral shaft refracture developed in 24 patients. Univariate analysis revealed that refracture was not statistically significantly associated with any of the above factors, except AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) classification type 32-D/4.2 and L2/L3 ratio (L2, length of femur fixed by the two screws farthest from the fracture line; L3, the total length from the greater trochanter to the distal end of femur; P < 0.001 and P = 0.0141, respectively). Multivariate analysis showed that PCCF classification type 32-D/4.2 and L2/L3 ratio were also independent risk factors for femoral refracture.ConclusionsFemoral shaft refracture is relatively common in children treated with external fixation. Because of the limited number of cases in this study, we cautiously concluded that the PCCF classification type 32-D/4.2 and L2/L3 ratio were independent risk factors for femoral shaft refracture in these patients.Level of evidenceIV

Long bone fractures in Cerdocyon thous: macroscopic and microstructural evaluation

Abstract The aim of the present study was to perform the macroscopic and microstructural morphological classification of long bone fractures of Cerdocyon thous. Eighteen cadavers of the species were necropsied, and subjected to radiographic and microscopical evaluation when long bone fractures were detected. Among the 18 cadavers, eight (44%) had fractures equally distributed (33.33%) in the femur, humerus, or tibia. More frequently (61.54%), the fractures were simple and affected the diaphysis, and in smaller proportions (23.08%) reached the physeal line. In diaphyseal and metaphyseal fractures, microscopical evaluation revealed cortical bone tissue, with longitudinal osteons that contained longitudinal and intermediate collagen fibres and lamellae with a delamination aspect. On the other hand, in epiphyseal fractures, trabecular bone tissue was more frequently observed, consisting of trabeculae with disorganised collagen fibres and absence of osteons. In both cases low activity, osteocytes, and low coverage of osteoblasts on the bone surface were noted. It was concluded that the frequency of fractures in the long bones of C. thous was 44%, with females being more predisposed. The findings support the hypothesis that fractures in such animals are caused by being run over by automobiles. The present study contributes significantly in alerting clinicians and surgeons to the types of fractures that C. thous is more predisposed to, its places of greatest occurrence, and its microstructure. Thus, there is a need for joint actions aimed at reducing the number of cases of wild animals being run over by automobiles.

Olecranon fractures in children: treatment of a rare entity.

Olecranon fractures are a rare entity in children. The classification and treatment strategies are still discussed controversially. A retrospective chart review of all patients < 17years admitted with an olecranon fracture at a Level I Trauma Center between 2005 and 2017 has been performed. 46 subjects were included. For classification of olecranon fractures in children the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO-PCCF) was used. Fractures were classified along the fracture line, dislocation, joint involvement and affection of the apophysis. For statistical analysis, a comparison of two groups was performed using Student t test. One-way ANOVA and Tukey's multiple comparison test was used to identify differences between more than two groups. For all analysis p ≤ 0.05 was considered statistically significant. The mean age of the children was 8.5years (2-16years). Most children were treated with a conservative therapy (n = 29, 63.0%). 17 patients (36.9%) underwent osteosynthesis (plate or tension band wiring) of which three were initially treated with a conservative therapeutic approach. Children with operative treatment were significantly older compared to children treated conservatively. Interestingly, all patients with luxation were characterized by an oblique fracture line, one of them extraarticular, three intraarticular. Taken together, this study analyzed one of the largest selections of pediatric patients with olecranon fracture in regard to fracture type and treatment strategy. Based on the assumption that treatment strategies follow a fracture classification, a consistent classification method is needed which should take into account fracture morphology and localization, as considered by the AO-PCCF, and the dislocation as measured by Braque. Surgical treatment is needed in case of dislocation ≥ 5mm, intra-articular fractures, instable fracture conditions caused by the fracture line, open fractures and the affection of the apophysis. Otherwise, the conservative treatment shows insufficient results in the elbow mobility. The reliable choice of treatments based on our classification was mirrored by the very low rate of conversion of treatment strategies. Level III-retrospective comparative study.

Perinatal Femoral Fracture: A Ten-Year Observational Case Series Study.

Background: perinatal femoral fractures (PFF) are relative rare birth-related fractures. Among treatment options, Bryant traction reported satisfactory outcomes in PFF of children under 3 years of age. The aim of this study is to assess the risk factors, diagnosis, management, and outcome in the 10-year multicentric experiences of all newborns treated for PFF in Catania city hospitals. Methods: 15,628 children, hospitalized in four neonatal units, were retrospectively reviewed. The following data were collected: gender, birth weight, gestational age, presentation, mode delivery, and fracture type according to AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF). In each case, diagnosis was achieved after the clinical examination and X-Ray exam. Each patient underwent Bryant’s skin traction of the affected limb, and was clinically followed for at least two years. Results: eight newborns were included in the study (five males). The average birth weight was 2.656 kg with a gestational age of 37.5 weeks; 4 cases were preterm birth; 5 patients had a cephalic presentation. According to the AO PCCF classification, three fractures were ranked 32-D/4.1 and five were 32-D/5.1. The entire cohort had an excellent outcome. Conclusions: prematurity, low birth weight, and caesarean section could be PFF risk factors. Bryant’s skin traction is an effective option to achieve an excellent outcome.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)

Background and purpose — To achieve a common understanding when dealing with long bone fractures in children, the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF) was introduced in 2007. As part of its final validation, we present the most relevant fracture patterns in the upper extremities of a representative population of children classified according to the PCCF.Patients and methods — We included children and adolescents (0–17 years old) diagnosed with 1 or more long bone fractures between January 2009 and December 2011 at the university hospitals in Bern and Lausanne (Switzerland). Patient charts were retrospectively reviewed and fractures were classified from standard radiographs.Results — Of 2,292 upper extremity fractures in 2,203 children and adolescents, 26% involved the humerus and 74% involved the forearm. In the humerus, 61%, and in the forearm, 80% of single distal fractures involved the metaphysis. In adolescents, single humerus fractures were more often epiphyseal and diaphyseal fractures, and among adolescents radius fractures were more often epiphyseal fractures than in other age groups. 47% of combined forearm fractures were distal metaphyseal fractures.Only 0.7% of fractures could not be classified within 1 of the child-specific fracture patterns. Of the single epiphyseal fractures, 49% were Salter-Harris type-II (SH II) fractures; of these, 94% occurred in schoolchildren and adolescents. Of the metaphyseal fractures, 58% showed an incomplete fracture pattern. 89% of incomplete fractures affected the distal radius. Of the diaphyseal fractures, 32% were greenstick fractures. 24 Monteggia fractures occurred in pre-school children and schoolchildren, and 2 occurred in adolescents.Interpretation — The pattern of pediatric fractures in the upper extremity can be comprehensively described according to the PCCF. Prospective clinical studies are needed to determine its clinical relevance for treatment decisions and prognostication of outcome.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)

Background and purpose — The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) describes the localization and morphology of fractures, and considers severity in 2 categories: (1) simple, and (2) multifragmentary. We evaluated simple and multifragmentary fractures in a large consecutive cohort of children diagnosed with long bone fractures in Switzerland.Patients and methods — Children and adolescents treated for fractures between 2009 and 2011 at 2 tertiary pediatric surgery hospitals were retrospectively included. Fractures were classified according to the AO PCCF. Severity classes were described according to fracture location, patient age and sex, BMI, and cause of trauma.Results — Of all trauma events, 3% (84 of 2,730) were diagnosed with a multifragmentary fracture. This proportion was age-related: 2% of multifragmentary fractures occurred in school­children and 7% occurred in adolescents. In patients diagnosed with a single fracture only, the highest percentage of multifragmentation occurred in the femur (12%, 15 of 123). In fractured paired radius/ulna bones, multifragmentation occurred in 2% (11 of 687); in fractured paired tibia/fibula bones, it occurred in 21% (24 of 115), particularly in schoolchildren (5 of 18) and adolescents (16 of 40). In a multivariable regression model, age, cause of injury, and bone were found to be relevant prognostic factors of multifragmentation (odds ratio (OR) > 2).Interpretation — Overall, multifragmentation in long bone fractures in children was rare and was mostly observed in adolescents. The femur was mostly affected in single fractures and the lower leg was mostly affected in paired-bone fractures. The clinical relevance of multifragmentation regarding growth and long-term functional recovery remains to be determined.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)

Background and purpose — To achieve a common understanding when dealing with long bone fractures in children, the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF) was introduced in 2007. As part of its final validation, we present the most relevant fracture patterns in the lower extremities of a representative population of children classified according to the PCCF.Patients and methods — We included patients up to the age of 17 who were diagnosed with 1 or more long bone fractures between January 2009 and December 2011 at either of 2 tertiary care university hospitals in Switzerland. Patient charts were retrospectively reviewed.Results — More lower extremity fractures occurred in boys (62%, n = 341). Of 548 fractured long bones in the lower extremity, 25% involved the femur and 75% the lower leg. The older the patients, the more combined fractures of the tibia and fibula were sustained (adolescents: 50%, 61 of 123). Salter-Harris (SH) fracture patterns represented 66% of single epiphyseal fractures (83 of 126). Overall, 74 of the 83 SH patterns occurred in the distal epiphysis. Of all the metaphyseal fractures, 74 of 79 were classified as incomplete or complete. Complete oblique spiral fractures accounted for 57% of diaphyseal fractures (120 of 211). Of all fractures, 7% (40 of 548) were classified in the category "other", including 29 fractures that were identified as toddler’s fractures. 5 combined lower leg fractures were reported in the proximal metaphysis, 40 in the diaphysis, 26 in the distal metaphysis, and 8 in the distal epiphysis.Interpretation — The PCCF allows classification of lower extremity fracture patterns in the clinical setting. Re-introduction of a specific code for toddler’s fractures in the PCCF should be considered.

Classification of long-bone fractures based on digital-geometric analysis of X-ray images

The classification of fractured of a patient plays an important role in orthopaedic evaluation and diagnosis. It not only aids in assessing the severity of the disease or injury but also serves as a basis of treatment or surgical correction. This paper proposes a novel approach to automated classification of long-bone fractures based on the analysis of an input X-ray image. The method consists of four major steps: (i) extraction of the bone-contour from a given X-ray image, (ii) identification of fracture-points or cracks, (iii) determination of an equivalent set of geometric features in tune with the Muller-AO clinical classification of fractures, and (iv) identification and detailed assessment of the fracture-type. The decision procedure makes use of certain geometric properties of digital curves such as relaxed digital straight line segments (RDSS), arcs, discrete curvature, and concavity index. The proposed method for the analysis of fractures is applied on different types of bone-images and is observed to have produced correct classification in most of the test-cases.

Evaluation of remote results of treatment of children with long-bone fractures of the lower extremities

Background. Evaluation of the effectiveness of treatment of long-bone fractures of the lower extremities should be comprehensive and include both subjective and objective indicators. In the developed countires, it is standard to assess the quality of life related to children’s health after trauma. According to the Russian literature, such assessment has not been studied. The aim of our study was to assess the quality of life in children, with long-bone fractures of the lower extremities, and to compare the results with data from the Lower Extremity Functional Scale (LEFS) and assessment system according to N.B. Duysenov.Materials and methods. We examined 70 patients (age range, 8–18 years) with long-bone fractures of the lower extremities. Forty patients had a history of tibia fracture, and 30 patients had a history of femoral fracture. We determined the severity of the fractures using pediatric comprehensive classification of long-bone fractures (PCCF). We assessed the quality of life of the children using the Pediatric Questionnaire for Quality of Life (PedsQLTM 4.0).Results. Trauma had a significant impact on the quality of life in children. The children evaluated their quality of life after injury more objectively; on all scales, their scores had the highest correlation with LEFS and assessment system according to N.B Duysenov. In most cases, parents underestimated the mental and physical burden of their child’s condition after injury. The values for the “physical functioning” assessment in children with severe trauma was the lowest, and was not significantly different between parents and children. Parents who were aware of the severity of the injury gave their child more attention, which positively affected the child’s psychological and social functioning. Children with severe trauma had higher values on the emotional, social and role functioning scale, compared to children with minor injuries.Conclusions. The results of all functional scales in the quality of life assessment, as assessed by the children themselves at different times after injury, had the highest correlation with LEFS and assessment system according to N.B. Duysenov. LEFS is the most informative for examining the consequences of fractures of different severity. There were no significant differences among the children with fractures of varying severity using the assessment system according to N.B. Duysenov.

An epidemiological evaluation of pediatric long bone fractures - a retrospective cohort study of 2716 patients from two Swiss tertiary pediatric hospitals.

BackgroundChildren and adolescents are at high risk of sustaining fractures during growth. Therefore, epidemiological assessment is crucial for fracture prevention. The AO Comprehensive Injury Automatic Classifier (AO COIAC) was used to evaluate epidemiological data of pediatric long bone fractures in a large cohort.MethodsData from children and adolescents with long bone fractures sustained between 2009 and 2011, treated at either of two tertiary pediatric surgery hospitals in Switzerland, were retrospectively collected. Fractures were classified according to the AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF).Age, sex, BMI, injury and treatment data were recorded. Children were classified into four age classes and five BMI classes were applied. Seven major accident categories were established. Study parameters were tabulated using standard descriptive statistics. The relationship of categorical variables was tested using the chi-square test. The Children’s BMI was compared to WHO reference data and Swiss population data.ResultsFor a total of 2716 patients (60% boys), 2807 accidents with 2840 long bone fractures (59% radius/ulna; 21% humerus; 15% tibia/fibula; 5% femur) were documented. Children’s mean age (SD) was 8.2 (4.0) years (6% infants; 26% preschool children; 40% school children; 28% adolescents). Adolescent boys sustained more fractures than girls (p < 0.001). The leading cause of fractures was falls (27%), followed by accidents occurring during leisure activities (25%), at home (14%), on playgrounds (11%), and traffic (11%) and school accidents (8%). There was boy predominance for all accident types except for playground and at home accidents. The distribution of accident types differed according to age classes (p < 0.001). Twenty-six percent of patients were classed as overweight or obese — higher than data published by the WHO for the corresponding ages — with a higher proportion of overweight and obese boys than in the Swiss population (p < 0.0001).ConclusionOverall, differences in the fracture distribution were sex and age related. Overweight and obese patients seemed to be at increased risk of sustaining fractures. Our data give valuable input into future development of prevention strategies. The AO PCCF proved to be useful in epidemiological reporting and analysis of pediatric long bone fractures.

Reliable classification of children’s fractures according to the comprehensive classification of long bone fractures by Müller

Background and purpose Guidelines for fracture treatment and evaluation require a valid classification. Classifications especially designed for children are available, but they might lead to reduced accuracy, considering the relative infrequency of childhood fractures in a general orthopedic department. We tested the reliability and accuracy of the Müller classification when used for long bone fractures in children.Methods We included all long bone fractures in children aged < 16 years who were treated in 2008 at the surgical ward of Stavanger University Hospital. 20 surgeons recorded 232 fractures. Datasets were generated for intra- and inter-rater analysis, as well as a reference dataset for accuracy calculations. We present proportion of agreement (PA) and kappa (K) statistics.Results For intra-rater analysis, overall agreement (κ) was 0.75 (95% CI: 0.68–0.81) and PA was 79%. For inter-rater assessment, K was 0.71 (95% CI: 0.61–0.80) and PA was 77%. Accuracy was estimated: κ = 0.72 (95% CI: 0.64–0.79) and PA = 76%.Interpretation The Müller classification (slightly adjusted for pediatric fractures) showed substantial to excellent accuracy among general orthopedic surgeons when applied to long bone fractures in children. However, separate knowledge about the child-specific fracture pattern, the maturity of the bone, and the degree of displacement must be considered when the treatment and the prognosis of the fractures are evaluated.

New Classification System for Long-bone Fractures Supplementing the AO/OTA Classification

This article describes a novel, clinically oriented classification system for long-bone fractures that is simple, reliable, and useful to predict treatment method, complications, and outcome. The reliability and memorability of the new classification were statistically tested and compared with the AO-Müller/Orthopaedic Trauma Association (AO/OTA) long-bone fracture classification. The proposed classification system was also clinically validated with a targeted pilot study designed for content and clinical outcome retrospectively reviewing 122 closed tibial shaft fractures, which were used as a representative paradigm of long-bone fractures. Statistical evaluation showed that the proposed classification system had improved inter- and intraobserver variation agreement and easier memorability compared with the AO/OTA classification system. The clinical validation study showed its predictive value regarding selection of treatment method, complication rate, and injury outcome.The proposed classification system proved simple, reliable, and memorable. Its clinical value appeared strong enough to justify the organization of larger studies for a complete assessment of its clinical usefulness for all long-bone fractures.

Development and validation of a paediatric long-bone fracture classification. A prospective multicentre study in 13 European paediatric trauma centres

BackgroundThe aim of this study was to develop a child-specific classification system for long bone fractures and to examine its reliability and validity on the basis of a prospective multicentre study.MethodsUsing the sequentially developed classification system, three samples of between 30 and 185 paediatric limb fractures from a pool of 2308 fractures documented in two multicenter studies were analysed in a blinded fashion by eight orthopaedic surgeons, on a total of 5 occasions. Intra- and interobserver reliability and accuracy were calculated.ResultsThe reliability improved with successive simplification of the classification. The final version resulted in an overall interobserver agreement of κ = 0.71 with no significant difference between experienced and less experienced raters.ConclusionsIn conclusion, the evaluation of the newly proposed classification system resulted in a reliable and routinely applicable system, for which training in its proper use may further improve the reliability. It can be recommended as a useful tool for clinical practice and offers the option for developing treatment recommendations and outcome predictions in the future.

The AO Comprehensive Classification of Pediatric Long-bone Fractures

The first AO comprehensive pediatric long-bone fracture classification system has been proposed following a structured path of development and validation with experienced pediatric surgeons. A Web-based multicenter agreement study involving 70 surgeons in 15 clinics and 5 countries was conducted to assess the reliability and accuracy of this classification when used by a wide range of surgeons with various levels of experience. Training was provided at each clinic before the session. Using the Internet, participants could log in at any time and classify 275 supracondylar, radius, and tibia fractures at their own pace. The fracture diagnosis was made following the hierarchy of the classification system using both clinical terminology and codes. kappa coefficients for the single-surgeon diagnosis of epiphyseal, metaphyseal, or diaphyseal fracture type were 0.66, 0.80, and 0.91, respectively. Median accuracy estimates for each bone and type were all greater than 80%. Depending on their experience and specialization, surgeons greatly varied in their ability to classify fractures. Pediatric training and at least 2 years of experience were associated with significant improvement in reliability and accuracy. Kappa coefficients for diagnosis of specific child patterns were 0.51, 0.63, and 0.48 for epiphyseal, metaphyseal, and diaphyseal fractures, respectively. Identified reasons for coding discrepancies were related to different understandings of terminology and definitions, as well as poor quality radiographic images. Results supported some minor adjustments in the coding of fracture type and child patterns. This classification system received wide acceptance and support among the surgeons involved. As long as appropriate training could be performed, the system classification was reliable, especially among surgeons with a minimum of 2 years of clinical experience. We encourage broad-based consultation between surgeons' international societies and the use of this classification system in the context of clinical practice as well as prospectively for clinical studies.