Gartland Classification of Supracondylar Humeral Fractures

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The Gartland system classifies extension-type supracondylar humerus fractures in children (the overwhelming majority — 95 to 98 percent) by degree of posterior displacement and cortical continuity. The original classification described three types; a fourth (multidirectional instability) was added later by Leitch.

• Flexion-type supracondylar fractures (2 to 5 percent) are far less common but have a different mechanism (direct fall on a flexed elbow) and the distal fragment displaces anteriorly. The Gartland classification was designed for extension types — apply it with caution to flexion injuries.
• Baumann angle (the humeral-capitellar angle on the AP view) should be approximately 72 to 75 degrees. A change from the contralateral side suggests rotational malalignment and may indicate the need for reduction in a Type II fracture.
• Type IV fractures are easily missed because they appear to reduce in both flexion and extension during fluoroscopy. The clue is instability in both planes during examination under anaesthesia. If the fragment is stable neither in flexion nor in extension, suspect Type IV.
• Open fractures (Type III with skin breach) need urgent irrigation and debridement alongside reduction and fixation, plus antibiotics.
• Timing: Reduction and pinning should be performed promptly but multiple studies have shown no difference in outcomes between operating within 8 hours versus the next morning for closed injuries presenting in the evening with a well-perfused hand. Swelling and compartment syndrome risk, not the clock, should dictate urgency.
• Cubitus varus (gunstock deformity) is the most common late complication and results from malrotation and medial column collapse — it is a cosmetic and functional problem (limited flexion, external rotation deformity) that may need a corrective supracondylar osteotomy later.
• Nerve injuries at presentation are seen in roughly 10 to 20 percent of Type III fractures. Most are neuropraxias that recover within 3 to 6 months. The AIN is most commonly injured by the proximal fragment poking anteriorly into the soft tissues; the radial nerve is injured less often by the proximal spike; the ulnar nerve is most at risk from the medial spike or iatrogenically from a medial pin.
• Compartment syndrome and Volkmann ischaemic contracture are rare but devastating — maintain a high index of suspicion with increasing pain (especially on passive extension of the fingers), anxiety, and worsening swelling.