Description and management aspects of a difficult fracture

1. Pediatric Gartland Type-IV
Supracondylar Humeral
Fractures
Prepared by Dr Madan Mohan based on recently published journals

2. •In 2006, Leitch et al. modified the
classification system to include a variant of
type-III fractures with multidirectional
instability resulting from circumferential loss
of the periosteal hinge.
•This rarer fracture type is referred to as a
modified Gartland type-IV fracture.

3. • Type-IV supracondylar humeral fracture is a rare
pattern that presents with severe instability in both
flexion and extension.
• These fractures cause considerable difficulty in the
achievement and maintenance of reduction by
means of pinning with use of closed methods and
may result in malalignment and a poor outcome.

4. Given the rarity of type-IV supracondylar
humeral fractures, determining the true
rate of injury is challenging, with reports
ranging from 3% to 9% of all operatively
treated supracondylar humeral fractures

5. •Because of its highly unstable nature, this type of
fracture poses great difficulty in achieving and
maintaining reduction with use of Kirschner wires
and therefore requires special techniques.
•Because of its highly unstable nature, this type of
fracture poses great difficulty in achieving and
maintaining reduction with use of Kirschner wires
and therefore requires special techniques.

6. Diagnosis of type-IV fracture was significantly more
likely given the presence of the following:
•Flexion angulation of the distal fragment
•Valgus angulation of the distal fragment
•Lateral translation of the distal fragment
•Osseous apposition (cortical contact) between the
proximal and distal fragments
•Fracture propagation toward the diaphysis

8. •The most strongly associated parameter was
flexion angulation of the distal fragment,
followed by valgus angulation, lateral
translation, and the presence of osseous
apposition between the proximal and distal
fracture fragments.
•It is likely that substantial overlap exists
between type- IV and flexion-type fractures.
(Please see presentation on flexion type of SC
fracture)

9. Fluoroscopic images showing the reduction
technique with use of the joystick method.

10. Illustration depicting the technique for reduction
with use of leverage in flexion-type
fracture.

11. Illustration depicting the technique for reduction
with use of leverage in extension-type
fracture.