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Eur J Pediatr Surg 2025; 35(04): 341-346
DOI: 10.1055/a-2536-4682
Original Article

Distal Humeral Coronal Shear Fractures in Children and Adolescents: Need for Cross-Sectional Imaging and a Revised Classification

Ralf Kraus 
1   Department of Trauma, Hand and Reconstructive Surgery, University Hospital Gießen, Gießen, Germany
,
Michael Esser
2   Department of Diagnostic and Interventional Radiology, University Hospital Tübingen, Tübingen, Germany
,
Hagen Schmal
3   Department of Orthopedics and Trauma Surgery, University Medical Center Freiburg, Freiburg, Germany
,
Florian Bergmann
4   Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwigs-Maximilians-University Munich, Munich, Germany
,
Mike Trück
5   Department of Pediatric Surgery, Children's Hospital Lucerne, Lucerne, Switzerland
,
Hans Joachim Kirschner
6   Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, Tübingen, Germany
,
Martin M. Kaiser
7   Department of Paediatric Traumatology and Surgery, University Hospital Halle (Saale) of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
8   Department of Pediatric Traumatology, Bergmannstrost Hospital Halle (Saale), Halle (Saale), Germany
,
Justus Lieber 
6   Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, Tübingen, Germany
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Abstract

Background

The classification of fractures is necessary to ensure a reliable means of communication for clinical interaction, research, and education. Distal humeral coronal plane shear fractures (CSFs) are very rare in the growing-age population, despite that multiple classification schemes exist.

Objective

The aim of this study was to assess the inter- and intrarater reliability of the four most commonly used CSF classifications and their role in guiding treatment decisions in everyday clinical practice.

Materials and methods

Fifty-one patients with CSFs were retrospectively analyzed in a multicenter study. Of these, X-rays in two planes of 20 randomly selected CSFs were given to eight independent raters for classification according to Dubberley, Bryan and Morgan, Murthy, and AO. Cohen's kappa statistic was used to assess interrater agreement and intrarater consistency. Intraclass correlation coefficient (ICC) estimates and 95% confidence intervals (CIs) were calculated. Reliability values were classified as excellent (ICC ≥0.8), substantial (ICC 0.61–0.80), moderate (ICC 0.41–0.6), fair (ICC 0.2–0.4), slight (ICC 0.00–0.2), and poor (ICC <0.00).

Results

All patients received x-rays in two planes initially. Cross-sectional imaging was added in 76.5% of cases (CT 58.8%, MRI 11.7%, both 5.9%). Interrater reliabilities were classified as fair for Dubberley (ICC 0.354; 95% CI 0.198, 0.573) and Bryan and Morgan (ICC 0.357; 95% CI 0.200, 0.576), slight for AO (ICC 0.226; 95% CI 0.100, 0.434), and poor for Murthy (ICC −0.012; 95% CI −0.063, 0.102). The Dubberley subtype showed slight agreement at lower ICC values (ICC 0.024, 95% CI −0.041, 0.161). The intrarater agreement was moderate to substantial for most of the eight raters and did not differ between the four classification systems. The rate of surgical treatment was 49/51 patients.

Conclusion

The most commonly used classification schemes for CSFs failed to achieve a substantial agreement among the raters. This is probably because the fracture patterns of CSF in adolescence and high adulthood differ significantly. An adaptation of the classification for pediatric and adolescent patients is necessary, but only for scientific purposes. Classification is not necessary for the clinical management of patients, as virtually all patients require surgical treatment.

Keywords

pediatric trauma - fracture classification - distal humeral fractures - rater reliability - X-ray


Publication History

Received: 29 March 2024

Accepted: 09 February 2025

Accepted Manuscript online:
11 February 2025

Article published online:
21 March 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 Letts M, Rumball K, Bauermeister S, McIntyre W, D'Astous J. Fractures of the capitellum in adolescents. J Pediatr Orthop 1997; 17 (03) 315-320
    Search in Google Scholar
  • 2 Trinh TQ, Harris JD, Kolovich GP, Griesser MJ, Schickendantz MS, Jones GL. Operative management of capitellar fractures: a systematic review. J Shoulder Elbow Surg 2012; 21 (11) 1613-1622
    Search in Google Scholar
  • 3 Frank JM, Saltzman BM, Garbis N, Cohen MS. Articular shear injuries of the capitellum in adolescents. J Shoulder Elbow Surg 2016; 25 (09) 1485-1490
    Search in Google Scholar
  • 4 McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am 1996; 78 (01) 49-54
    Search in Google Scholar
  • 5 McKee MD, Veillette CJ, Hall JA. et al. A multicenter, prospective, randomized, controlled trial of open reduction–internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg 2009; 18 (01) 3-12
    Search in Google Scholar
  • 6 Dubberley JH, Faber KJ, Macdermid JC, Patterson SD, King GJ. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg Am 2006; 88 (01) 46-54
    Search in Google Scholar
  • 7 Murthy PG, Vuillermin C, Naqvi MN, Waters PM, Bae DS. Capitellar fractures in children and adolescents: classification and early results of treatment. J Bone Joint Surg Am 2017; 99 (15) 1282-1290
    Search in Google Scholar
  • 8 Slongo TF, Audigé L, Group AOPC. AO Pediatric Classification Group. Fracture and dislocation classification compendium for children: the AO pediatric comprehensive classification of long bone fractures (PCCF). J Orthop Trauma 2007; 21 (10 Suppl): S135-S160
    Search in Google Scholar
  • 9 Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma 2018; 32 (Suppl. 01) S1-S170
    Search in Google Scholar
  • 10 Kraus R, Lieber J, Schwerk P. et al. Incidence, treatment techniques, and results of distal humeral coronal shear fractures in children and adolescents-a multicenter study of the German Section of Pediatric Traumatology (SKT). Eur J Trauma Emerg Surg 2023; 50: 2673-2679
    Search in Google Scholar
  • 11 Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 2016; 15 (02) 155-163
    Search in Google Scholar
  • 12 Ashwood N, Verma M, Hamlet M, Garlapati A, Fogg Q. Transarticular shear fractures of the distal humerus. J Shoulder Elbow Surg 2010; 19 (01) 46-52
    Search in Google Scholar
  • 13 Lamas C, Grau A, Almenara M, Trigo L. Coronal shear fractures of the capitellum and trochlea: interobserver variability in classifying the fracture and the need for a computed tomography scan for the correct surgical planning. JSES Int 2020; 5 (02) 314-319
    Search in Google Scholar
  • 14 Dietz SO, Burkhart KE, Nowak TE, Rommens PM, Müller LP. Distal humerus fractures in the elderly: osteosynthesis or endoprosthesis? Review of the literature. Eur J Trauma Emerg Surg 2012; 38 (06) 605-615
    Search in Google Scholar
  • 15 Palvanen M, Kannus P, Niemi S, Parkkari J. Secular trends in distal humeral fractures of elderly women: nationwide statistics in Finland between 1970 and 2007. Bone 2010; 46 (05) 1355-1358
    Search in Google Scholar
  • 16 Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Open reduction and internal fixation of capitellar fractures with headless screws. Surgical technique. J Bone Joint Surg Am 2009; 91 (Suppl 2 Pt 1): 38-49
    Search in Google Scholar
  • 17 Raux S, Madelaine A. Sequelae of childhood elbow fracture. Orthop Traumatol Surg Res 2023; 109 (1S): 103454
    Search in Google Scholar
  • 18 Grantham SA, Norris TR, Bush DC. Isolated fracture of the humeral capitellum. Clin Orthop Relat Res 1981; (161) 262-269
    Search in Google Scholar
  • 19 Shergold S, Derias M, Moverley R, Murphy RJ, Guryel E, Phadnis J. Coronal shear fractures of the distal humerus managed according to the Modified Dubberley Classification System. J Shoulder Elbow Surg 2022; 31 (01) 133-142
    Search in Google Scholar
  • 20 Hasan SA, Fisher K, Henn RF, Gilotra M. Coronal plane articular shear fractures of the distal humerus. J Am Acad Orthop Surg 2023; 31 (05) e235-e245
    Search in Google Scholar
  • 21 Jacquot A, Poussange N, Charrissoux JL. et al. Usefulness and reliability of two- and three-dimensional computed tomography in patients older than 65 years with distal humerus fractures. Orthop Traumatol Surg Res 2014; 100 (03) 275-280
    Search in Google Scholar
  • 22 Vicenti G, Bizzoca D, Zaccari D. et al. Choice of treatments of the coronal shear fractures of the humerus. A national survey of Italian AO members. Injury 2023; 54 (Suppl. 01) S78-S84
    Search in Google Scholar
  • 23 Watts AC, Morris A, Robinson CM. Fractures of the distal humeral articular surface. J Bone Joint Surg Br 2007; 89 (04) 510-515
    Search in Google Scholar
  • 24 Brouwer KM, Lindenhovius AL, Dyer GS, Zurakowski D, Mudgal CS, Ring D. Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures. J Shoulder Elbow Surg 2012; 21 (06) 772-776
    Search in Google Scholar
  • 25 Doornberg J, Lindenhovius A, Kloen P, van Dijk CN, Zurakowski D, Ring D. Two and three-dimensional computed tomography for the classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy. J Bone Joint Surg Am 2006; 88 (08) 1795-1801
    Search in Google Scholar
  • 26 Nakamura Y, Tsubo K, Sasaki N. et al. Conservative treatment for coronal shear fracture of the distal humerus: a case report. JSES Rev Rep Tech 2022; 2 (04) 580-583
    Search in Google Scholar
  • 27 Stavrakakis IM, Sylignakis P, Magarakis GE, Ntontis Z, Chaniotakis C, Alvanos A. Capitellum and trochlea fractures. A systematic review of the literature. J Clin Orthop Trauma 2022; 31: 101922
    Search in Google Scholar
  • 28 Durakbasa MO, Gumussuyu G, Gungor M, Ermis MN. Distal humeral coronal plane fractures: management, complications and outcome. J Shoulder Elbow Surg 2013; 22 (04) 560-566
    Search in Google Scholar
  • 29 Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of the humerus. J Bone Joint Surg Am 2003; 85 (02) 232-238
    Search in Google Scholar