Reliable classification of children's fractures according to the comprehensive classification of long bone fractures by Müller

Terje Meling, Knut Harboe, Cathrine H Enoksen, Morten Aarflot, Astvaldur J Arthursson, Kjetil Søreide, Terje Meling, Knut Harboe, Cathrine H Enoksen, Morten Aarflot, Astvaldur J Arthursson, Kjetil Søreide

Abstract

Background and purpose: Guidelines for fracture treatment and evaluation require a valid classification. Classifications especially designed for children are available, but they might lead to reduced accuracy, considering the relative infrequency of childhood fractures in a general orthopedic department. We tested the reliability and accuracy of the Müller classification when used for long bone fractures in children.

Methods: We included all long bone fractures in children aged < 16 years who were treated in 2008 at the surgical ward of Stavanger University Hospital. 20 surgeons recorded 232 fractures. Datasets were generated for intra- and inter-rater analysis, as well as a reference dataset for accuracy calculations. We present proportion of agreement (PA) and kappa (K) statistics.

Results: For intra-rater analysis, overall agreement (κ) was 0.75 (95% CI: 0.68-0.81) and PA was 79%. For inter-rater assessment, K was 0.71 (95% CI: 0.61-0.80) and PA was 77%. Accuracy was estimated: κ = 0.72 (95% CI: 0.64-0.79) and PA = 76%.

Interpretation: The Müller classification (slightly adjusted for pediatric fractures) showed substantial to excellent accuracy among general orthopedic surgeons when applied to long bone fractures in children. However, separate knowledge about the child-specific fracture pattern, the maturity of the bone, and the degree of displacement must be considered when the treatment and the prognosis of the fractures are evaluated.

Figures

Figure 1.
Figure 1.
The Müller classification of long bone fractures.
Figure 2.
Figure 2.
The rule of the square: “The proximal and distal segments of long bones are defined by a square whose sides are the same length as the widest part of the epiphysis” (Müller et al. 1990). Müller classification: The width defined by both bones. The reference line defined as the most distal (or proximal) part of the bone. Li-La classification (and in this study): The width defined by one bone (radius). The reference line defined as the epiphyseal plate. AO pediatric classification: The width defined by both bones. The reference line defined as the epiphyseal plate. The proximal lines of the squares define the border between the diaphysis and the metaphysis. The fracture illustrated is defined as a forearm shaft fracture according to the Müller and Li-La classifications (and in this study), and as a distal forearm fracture according to the AO pediatric classification.

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