title: Does the Modified Gartland Classification Clarify Decision Making?
abstract: OBJECTIVE
  The modified Gartland classification system for pediatric supracondylar fractures is often utilized as a communication tool to aid in determining whether or not a fracture warrants operative intervention. This study sought to determine the interobserver and intraobserver reliability of the Gartland classification system, as well as to determine whether there was agreement that a fracture warranted operative intervention regardless of the classification system.
  
  
  METHODS
  A total of 200 anteroposterior and lateral radiographs of pediatric supracondylar humerus fractures were retrospectively reviewed by 3 fellowship-trained pediatric orthopaedic surgeons and 2 orthopaedic residents and then classified as type I, IIa, IIb, or III. The surgeons then recorded whether they would treat the fracture nonoperatively or operatively. The κ coefficients were calculated to determine interobserver and intraobserver reliability.
  
  
  RESULTS
  Overall, the Wilkins-modified Gartland classification has low-moderate interobserver reliability (κ=0.475) and high intraobserver reliability (κ=0.777). A low interobserver reliability was found when differentiating between type IIa and IIb (κ=0.240) among attendings. There was moderate-high interobserver reliability for the decision to operate (κ=0.691) and high intraobserver reliability (κ=0.760). Decreased interobserver reliability was present for decision to operate among residents. For fractures classified as type I, the decision to operate was made 3% of the time and 27% for type IIa. The decision was made to operate 99% of the time for type IIb and 100% for type III.
  
  
  CONCLUSIONS
  There is almost full agreement for the nonoperative treatment of Type I fractures and operative treatment for type III fractures. There is agreement that type IIb fractures should be treated operatively and that the majority of type IIa fractures should be treated nonoperatively. However, the interobserver reliability for differentiating between type IIa and IIb fractures is low. Our results validate the Gartland classfication system as a method to help direct treatment of pediatric supracondylar humerus fractures, although the modification of the system, IIa versus IIb, seems to have limited reliability and utility. Terminology based on decision to treat may lead to a more clinically useful classification system in the evaluation and treatment of pediatric supracondylar humerus fractures.
  
  
  METHODS
  Level III-diagnostic studies.
authors.affiliation: Department of Orthopaedics, University of Maryland School of Medicine, Timonium.
authors.forename: Sophia
authors.initials: S
authors.lastname: Leung
authors.affiliation: Department of Orthopaedics, University of Maryland School of Medicine, Timonium.
authors.forename: Ebrahim
authors.initials: E
authors.lastname: Paryavi
authors.affiliation: St Christopher's Hospital for Children, Philadelphia, PA.
authors.forename: Martin J
authors.initials: MJ
authors.lastname: Herman
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Paul D
authors.initials: PD
authors.lastname: Sponseller
authors.affiliation: Department of Orthopaedics, University of Maryland School of Medicine, Timonium.
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Abzug
mesh_terms: D000293:Adolescent; D002648:Child; D003661:Decision Support Techniques; D004551:Elbow Joint / Q000000981:diagnostic imaging*; D006801:Humans; D006810:Humeral Fractures / Q000145:classification* / Q000000981:diagnostic imaging / Q000628:therapy; D015588:Observer Variation; D011859:Radiography; D015203:Reproducibility of Results; D012189:Retrospective Studies; D000092464:Elbow Injuries