LAUSR

We read with interest the publication by Barik et al.1 Leitch et al.2 stated that Gartland type IV fractures may occur iatrogenically during attempted reduction of an extension-type fracture. Such an intraoperative conversion of a type III to a type IV would preclude a preoperative radiographic prediction. The possibility of an iatrogenic creation of a multidirectional type-IV instability was not mentioned by Barik et al.1 but is supported by their finding that 64.7% of type-IV fractures had attempts of closed reduction in other units. Barik et al.1 stated that there is scant literature regarding the optimum treatment for type-IV fractures, but Leitch et al.2 described a clear step-by-step treatment protocol, which was listed by Skaggs and Flynn3 as the recommended technique to treat type-IV fractures. Barik et al.1 reported a 7 to 10% incidence of type-IV fractures for all operated supracondylar fractures, referencing Leitch et al.,2 but the latter documented an incidence of only 3% (9 of 297 fractures). Mitchell et al.4 identified an incidence of 1.3% (3,040 fractures) with a type IV/III ratio of 39/156, which is much lower than the IV/III ratio of 17/16 reported by Barik et al.1 The latter authors reported that one important limitation of their study is that a few surgeries were performed by pediatric orthopedic fellows, which might have influenced the fracture classification. A possible misclassification of type IIIs as type IVs could have contributed to the large discrepancy between the authors’ high type-IV rate of 51.5% and the 20% reported byMitchell et al.4 in addition to the possibility of type IVs having been created during multiple reduction attempts by less experienced pediatric orthopedic fellows. If multidirectional instability is caused by the initial trauma because of more extensive soft-tissue disruption than we would expect to find a higher associated neurovascular injury (NVI) ratewith type-IV fractures, as shownby Mitchell et al.4 (III: 15%; IV: 28%). Ho et al.5 identified a