Clinical Orthopaedics
Clin Orthop Relat Res (2015) 473:738–741
DOI 10.1007/s11999-014-4033-8
IN BRIEF
Classifications In Brief: The Gartland Classification
of Supracondylar Humerus Fractures
Timothy B. Alton MD, Shawn E. Werner MD,
Albert O. Gee MD
Received: 22 July 2014 / Accepted: 22 October 2014 / Published online: 1 November 2014
Ó The Association of Bone and Joint Surgeons1 2014
History
Supracondylar humerus fractures are the most common
elbow injury in pediatric patients [24]. During the 1950s,
these injuries were called the ‘‘misunderstood fracture,’’ as
such injuries often resulted in bony deformity and Volk-
mann’s contracture [12]. In 1959, Gartland described a
simple classification scheme to reemphasize principles
underlying treatment of patients with a supracondylar
humerus fracture and discussed a method of injury man-
agement that has proven to be practical and effective with
time [12].
Supercondylar humerus fractures occur proximal to the
articular surface of the distal humerus and may be trans-
verse, oblique, or jagged. Gartland described a rotatory and
translational deformity, with posterior displacement
(extension) of the distal fragment occurring most often
[12]. He described three types of extension injury based on
degree of displacement: type I, nondisplaced; type II,
moderately displaced; and type III, severely displaced
injury, and he considered flexion-type injuries separately
[12].
Each author certifies that he or she, or a member of his or her
immediate family, has no funding or commercial associations (eg,
consultancies, stock ownership, equity interest, patent/licensing
arrangements, etc) that might pose a conflict of interest in connection
with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical
Orthopaedics and Related Research editors and board members are
on file with the publication and can be viewed on request.
T. B. Alton (&), S. E. Werner, A. O. Gee
Department of Orthopaedics and Sports Medicine, University of
Washington, 7201 6th Avenue, NE, #102, Seattle, WA 98115,
USA
e-mail: altont@uw.edu
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and Related Research®
A Publication of The Association of Bone and Joint Surgeons®
Purpose
Gartland [12] first described a treatment algorithm to allow
widespread management of the common but previously
misunderstood supracondylar humerus fracture to decrease
the incidence of malunion and Volkmann’s contracture.
Nondisplaced fractures were to be immobilized in a plaster
cast with the forearm flexed 75° to 80° in neutral rotation
without manipulative reduction. He emphasized the
importance of a detailed neurologic and vascular exami-
nation and cautioned against applying a cast that was too
tight or flexing the elbow past 80°. For moderate dis-
placement, closed reduction and casting with the patient
under general anesthesia was the preferred treatment. If
radiographs obtained 24 hours later showed residual or
recurrent displacement, the fracture was considered
unstable, and ulna-based overhead skeletal traction was
indicated. For severely displaced fractures, the same
algorithm was used, with Gartland noting an increased
number of unstable fractures and neurologic and vascular
injuries [12]. In 1963, he reported there may be a role for
open reduction of displaced, unstable fractures and stabil-
ization with thin stainless steel wires [13].
Treatment of pediatric supracondylar humerus fractures
has evolved since Gartland’s first description [12]; how-
ever, current treatment recommendations from the
American Academy of Orthopaedic Surgeons remain based
on the modified Gartland classification [2, 10, 21]. Type I
injuries are immobilized with a cast for 3 to 4 weeks, with
radiographic alignment checked at 1 week. Type IIA
injuries can be treated with closed reduction and casting or
percutaneous pinning, whereas type IIB injuries should
have closed reduction and percutaneous pinning to prevent
coronal and/or rotational malalignment. Types III and IV
Volume 473, Number 2, February 2015 The Gartland Classification 739

injuries also are treated with closed reduction and percu- Wilkins [22] modified the Gartland classification to
taneous pinning, as are flexion-type injuries, with possible make it more clinically relevant, including the concept of
open reduction and internal fixation if closed reduction is posterior humeral cortical contact. Extension type I injuries
unsuccessful [2]. Treatment details, such as the number of were nondisplaced; type II injuries were displaced anteri-
pins, medial versus lateral pin placement, requirement to orly (anterior humeral line anterior to capitellum [Fig. 1])
observe and protect the ulnar nerve with medial pin
placement, and construct biomechanical stability have been
discussed [2]. Open reduction—lateral, medial, or anterior
approach—is indicated for an open fracture when irrigation
and débridement are needed, when a closed reduction is
unsuccessful, and for treatment of fractures associated with
a dysvascular limb (pulseless, not pink hand) [21]. Traction
suspension [12] rarely is used in modern medicine and is
reserved for cases where anesthetic is unavailable or
patient comorbidities make its use unsafe, when no quali-
fied surgeon is available to perform the procedure, or as a
temporizing measure as soft tissue swelling resolves [21].
Gartland highlighted Volkmann’s contracture—now
known to be a complication of untreated compartment syn-
drome of the forearm—as one of the reasons for physician
trepidation when treating supracondylar humerus fractures
[12]. Guidelines for prompt treatment of these fractures,
increased vigilance for detection of the clinical and physio-
logic manifestations of compartment syndrome, and adequate
emergent fasciotomies have decreased rates of contracture; Fig. 1 The anterior humeral line should cross the capitellum on a true
but compartmental syndrome still develops in 0.1% to 0.3% of lateral view of an uninjured elbow.
patients with a sypracondylar humerus fracture [5]. Com-
partment syndrome is more likely to occur as the energy of
injury and degree of fracture displacement increase, but it can
occur with all Gartland fracture patterns [20, 21].

Description of the Gartland Classification

Gartland extension type I injuries generally are nondis-

placed transverse fractures. Generalized swelling about the
elbow could be present; however, no evidence of nerve or
vascular compromise is expected. Extension type II frac-
tures originally were described as ‘‘moderately posteriorly
displaced’’, rotated and often requiring reduction [12].
Extension (type III) fractures often have oblique patterns
with severe displacement and rotation. As the displacement
increased, so too did the risk of neurologic or vascular
injury [12, 18].
In 1982, Abraham et al. [1] created supracondylar
humerus fractures in monkey cadavers by loading the
extremity and then analyzing the periosteal injury per each
Gartland extension-type injury. In type I injuries, the
anterior periosteum was found to be intact but detached
from the anterior surface of the humerus by up to 3 cm,
Fig. 2 Baumann’s angle is a radiographic angle created by the
whereas types II and III injuries had a torn anterior peri- intersection of a line drawn down the humeral axis (A) and a line
osteum but an intact posterior hinge that reduced with load drawn along the physis (B) of the lateral condyle of the elbow on the
removal and fracture reduction [1]. AP view of the elbow (normal range, 9°–26°) [24]. a = angle.

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740 Alton et al. Clinical Orthopaedics and Related Research1

Fig. 3A–C Lateral radiographs are shown for Gartland (A) type I, (B) type II, and (C) type III supracondylar humerus fractures.

but had posterior humeral cortical contact; and type III Table 1. Modified Gartland classification of supracondylar humerus
fractures were displaced with no cortical contact. Wilkins fractures [10, 21]
also subdivided type II injuries into IIA and IIB categories: Fracture type Characteristics Comments
IIA fractures have no rotational abnormality or fragment
translation, and IIB injuries do, resulting in more instability I Minimal Fat pad elevation on radiographs
displacement
[22].
II Posterior hinge Anterior humeral line anterior to
In 1995, De Boeck et al. [10] described a subtype of capitellum
supracondylar humerus fracture where the medial column III Displaced No cortical contact
of the humerus is comminuted and unstable, leading to loss IV Displaced in Flexion and extension instability
of Baumann’s angle (Fig. 2) and the recommendation for extension and demonstrated radiographically
closed reduction with percutaneous pinning. In 2006, Le- flexion
itch et al. [16] suggested the addition of a type IV injury Medial comminution Collapse of medial column
believed to be difficult to treat owing to multiplanar Loss of
instability, identified intraoperatively, from no intact peri- Baumann
angle
osteal hinge [16] (Fig. 3; Table 1).

De Gheldere et al. [11] evaluated the reliability of the

Reliability
Barton et al. [4] evaluated the reliability of the modified
Gartland classification, using a version modified by Wil-
kins et al. in 1996 [23], which included three types of
fracture based on the amount of displacement and posterior
cortical hinge. Type IV and the medial column comminu-
tion subtypes had not yet been added at the time of their
work. Barton et al. [4] used five different reviewers of 50
extension-type supracondylar humerus fractures at three
different times. They found after a 2-week interval that
90% of the fractures were classified the same way with an
intraobserver kappa value of 0.84. At 3 years, review of the
same radiographs led to 89% of fractures being likewise
classified, with a kappa value of 0.81. Most disagreement
was encountered when differentiating type I from type II
injuries, which is concerning because the indicated treat-
ment for type I injuries is casting, while closed reduction
and percutaneous pinning are suggested for type II injuries
[5]. At least three of five reviewers agreed on the classifi-
cation of all 50 cases at all three times. Interobserver
reliability was determined to be 0.74 [4].
Lagrange and Rigault classification with 100 supracondylar
humerus fractures and five different observers on two
separate occasions. They found intraobserver reliability to
be 0.76 and interobserver reliability was 0.69, similar to
data for the Gartland classification [11].
Limitations
While the Gartland classification does not specifically incor-
porate neurovascular compromise, vascular injury has been
found to occur almost exclusively in extension type III or
higher supracondylar humerus fractures [17], and these inju-
ries were not considered in Gartland’s classification. The
brachial artery can be occluded, in spasm, entrapped, severed,
or tethered by the proximal fragment of the supracondylar
fracture before or after reduction. It was reported that the
radial pulse is absent on initial presentation in 7% to 12% of
patients with supracondylar fractures [14], but an occluded or
tethered artery may recover with adequate fracture reduction
[15] with the incidence of impaired circulation after an ade-
quate fraction reduction less than 0.8% [8, 14]. Decisions to

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explore the brachial artery surgically are based on extremity
perfusion, not the presence or absence of a pulse [21].
Gartland also recognized that nerve injuries often were
associated with supracondylar humerus fractures [12], but
these were not addressed in his classification. It now is
known that nerve injuries are the most frequent compli-
cation associated with such fractures, occurring in 11.3%
of cases [3]. Primary nerve injuries are believed to result
from tenting of the nerve on the sharp proximal fragment or
entrapment of the nerve in the fracture site [19]. Gartland
noted that most nerve injuries were transient and recom-
mended initial treatment as if no nerve damage was present
[12]. Several studies have supported this, with 86% to
100% of nerve injuries reported to be neurapraxias, which
spontaneously resolve [6, 7, 9, 19].
The fracture pattern described by Gartland correlates
with the pattern of nerve injury [12]. Extension-type frac-
tures, which are the most common, put the anterior
interosseous nerve at greatest risk of injury [3]. Of exten-
sion-type fractures, traumatic neurapaxia occurred with a
weighted event rate of 11.3%, affecting the anterior inter-
osseous nerve in 34.1% of traumatic neurapraxias [3]. Less
common flexion-type fractures are associated with a
weighted event rate of neurapraxia of 16.6%, affecting the
ulnar nerve in 91.3% of cases [3].
Conclusions
The Gartland classification is a commonly used system for
evaluation and treatment of supracondylar humerus fractures
in children. It has good interobserver and intraobserver reli-
ability and Type III injuries are commonly associated with
neurovascular injuries, where there should be heightened
awareness. Gartland recognized the major complications
associated with supracondylar humerus fractures and his work
remains the foundation for modern treatment of these injuries.
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