Lutz Nicolas, Audigé Laurent, Schmittenbecher Peter, Clavert Jean-Michel, Frick Steve, Slongo Theddy
Service de Chirurgie Pediatrique CHUV-HEL, Lausanne, Switzerland.
J Pediatr Orthop. 2011 Mar;31(2):117-23. doi: 10.1097/BPO.0b013e3182073fa2.
The first AO comprehensive pediatric long bone fracture classification system has been established following a structured path of development and validation with experienced pediatric surgeons.
A follow-up series of agreement studies was applied to specify and evaluate a grading system for displacement of pediatric supracondylar fractures. An iterative process comprising an international group of 5 experienced pediatric surgeons (Phase 1) followed by a pragmatic multicenter agreement study involving 26 raters (Phase 2) was used. The last evaluations were conducted on a consecutive collection of 154 supracondylar fractures documented by standard anteroposterior and lateral radiographs.
Fractures were classified according to 1 of 4 grades: I=incomplete fracture with no or minimal displacement; II=Incomplete fracture with continuity of the posterior (extension fracture) or anterior cortex (flexion fracture); III=lack of bone continuity (broken cortex), but still some contact between the fracture planes; IV=complete fracture with no bone continuity (broken cortex), and no contact between the fracture planes. A diagnostic algorithm to support the practical application of the grading system in a clinical setting, as well as an aid using a circle placed over the capitellum was proposed. The overall κ coefficients were 0.68 and 0.61 in the Phase 1 and Phase 2 studies, respectively. In the Phase 1 study, fracture grades I, II, III, and IV were classified with median accuracies of 91%, 82%, 83%, and 99.5%, respectively. Similar median accuracies of 86% (Grade I), 73% (Grade II), 83% (Grade III), and 92% were reported for the Phase 2 study. Reliability was high in distinguishing complete, unstable fractures from stable injuries [ie, κ coefficients of 0.84 (Phase 1) and 0.83 (Phase 2) were calculated]; in Phase 2, surgeons' accuracies in classifying complete fractures were all above 85%.
With clear and unambiguous definition, this new grading system for supracondylar fracture displacement has proved to be sufficiently reliable and accurate when applied by pediatric surgeons in the framework of clinical routine as well as research.
Diagnostic study, Level II.
首个AO小儿长骨骨折综合分类系统是在与经验丰富的小儿外科医生共同经历了结构化的开发和验证过程后建立的。
应用一系列随访一致性研究来明确和评估小儿髁上骨折移位的分级系统。采用了一个迭代过程，包括一个由5名经验丰富的小儿外科医生组成的国际小组（第1阶段），随后是一项涉及26名评估者的实用多中心一致性研究（第2阶段）。最后的评估是对154例经标准正位和侧位X线片记录的髁上骨折进行连续收集后进行的。
骨折根据4个等级之一进行分类：I级=无移位或轻微移位的不完全骨折；II级=后皮质（伸展型骨折）或前皮质（屈曲型骨折）连续的不完全骨折；III级=骨连续性中断（皮质断裂），但骨折平面之间仍有一些接触；IV级=完全骨折，骨连续性中断（皮质断裂），且骨折平面之间无接触。提出了一种支持该分级系统在临床环境中实际应用的诊断算法，以及一种使用置于肱骨小头上方的圆圈的辅助方法。在第1阶段和第2阶段研究中，总体κ系数分别为0.68和0.61。在第1阶段研究中，I级、II级、III级和IV级骨折的分类中位准确率分别为91%、82%、83%和99.5%。第2阶段研究报告的类似中位准确率分别为86%（I级）、73%（II级）、83%（III级）和92%。在区分完全性、不稳定骨折与稳定损伤方面可靠性较高[即计算得出第1阶段κ系数为0.84，第2阶段为0.83]；在第2阶段，外科医生对完全骨折的分类准确率均高于85%。
该新的髁上骨折移位分级系统定义清晰明确，在小儿外科医生用于临床常规及研究时，已证明具有足够的可靠性和准确性。
诊断性研究，II级。
