Documentation of fracture severity with the AO classification of pediatric long-bone fractures

Figures & data

Figure 1. Overall structure of the pediatric fracture classification. From Slongo et al. (2006b).

Figure 2. Coding of pediatric long bones and localization of fractures.

Table 1.  Specific patterns of pediatric fractures (child code)

Epiphysis	Metaphysis	Diaphysis
/1 Salter - Harris I		/1 Bowing fracture
/2 Salter - Harris II	/2 Buckle or greenstick	/2 Greenstick fracture
/3 Salter – Harris III	/3 Complete fracture
/4 Salter – Harris IV		/4 Transverse fracture < 30°
/5 Two-plane fracture		/5 Oblique / spiral fracture < 30°
/6 Tri-plane fracture		/6 Monteggia lesion
/7 Ligament avulsion	/7 Ligament avulsion	/7 Galeazzi lesion
/8 Flake fracture
/9 Other fractures	/9 Other fractures	/9 Other fractures,
		incl. toddler fracture a

^a Toddler fractures were initially given the code /3, but according to Slongo et al. (2006a) these fractures were not reliably documented. The code /9 should be given to any fractures not fitting into one of the other anticipated patterns.

Figure 3. Definition of fracture severity code and proposed simplification. The classification of fracture severity was developed and evaluated with 3 categories. Our results suggest that the two more severe categories should be combined.

Figure 4. Distribution of the number of fractures in relation to the percentage of surgeons classifying epiphyseal, metaphyseal, and diaphyseal fractures as wedge or complex.

Table 2.  Raters’ pairwise kappa for classification of severity codes

	Epiphyseal		Metaphyseal		Diaphyseal
	n (%)	kappa	n (%)	kappa	n (%)	kappa
Study A
Number of ratings per case	5			5		4–5
Full agreement (100% of raters)	45 (85)			106 (97)		97 (94)
1 – simple	55	–	107	0.79	95	0.82
2 – wedge	–		1	–	7	0.82
3 – complex	–		1	–	1	–
Overall kappa						0.82
Study B
Number of ratings per case	35–69		41–70		42–70
Full agreement (100% of raters)	14 (31)		58 (54)		55 (47)
1 – simple	42	0.13	106	0.34	105	0.61
2 – wedge	–		1		8	0.37
3 – complex	–		–		4	–
Overall kappa						0.51

Figure 5. Surgeons’ median and ranges of accuracy of classifying the severity (simple versus wedge/complex) of epiphyseal, metaphyseal, and diaphyseal fractures.

Figure 6. Two cases for which surgeons disagreed in identification of the severity.

Slongo T, Audigé L, Schlickewei W, Clavert J M, Hunter J. Development and validation of the AO., pediatric comprehensive classification of long bone fractures by the Pediatric Expert Group of the AO Foundation in collaboration with AO Clinical Investigation and Documentation and the International Association for Pediatric Traumatology. J Pediatr Orthop 2006; 26: 43–9

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