Distal humerus elbow fractures are one of the most common traumatic fractures seen in pediatric patients and present as three main types: Supracondylar (SC), lateral condyle (LC), and medial epicondyle (ME) fractures.

To evaluate the epidemiology of pediatric distal humerus fractures (SC, LC, and ME) from an American insurance claims database.

A retrospective review was performed on patients 17 years and younger with the ICD 9 and 10 codes for SC, LC and ME fractures based on the IBM Truven MarketScan® Commercial and IBM Truven MarketScan Medicare Supplemental databases. Patients from 2015 to 2020 were queried for treatments, patient age, sex, length of hospitalization, and comorbidities.

A total of 1133 SC, 154 LC, and 124 ME fractures were identified. SC fractures had the highest percentage of operation at 83%, followed by LC (78%) and ME fractures (41%). Male patients were, on average, older than female patients for both SC and ME fractures.

In the insurance claims databases used, SC fractures were the most reported, followed by LC fractures, and finally ME fractures. Age was identified to be a factor for how a pediatric distal humerus fractures, with patients with SC and LC fractures being younger than those with ME fractures. The peak age per injury per sex was similar to reported historic central tendencies, despite reported trends for younger physiologic development.

Isolated medial epicondyle fracture constitutes a common fracture in children's and adolescent's elbow and is highly associated with an elbow dislocation. Cases with bilateral medial epicondyle fracture with concomitant elbow dislocation have been previously described in literature, while cases without an associated elbow dislocation are lacking. In this article, a bilateral medial epicondyle fracture without elbow dislocation in an adolescent high-level gymnast athlete is reported. To the best of the authors' knowledge, this is the first case report in literature regarding such an extremely rare traumatic elbow injury.

Athletes with medial epicondyle nonunions typically present with medial elbow pain, an elbow flexion contracture, and the inability to compete. The purpose of this study was to evaluate the clinical outcomes of patients who underwent medial epicondyle excision with ulnar collateral ligament and flexor-pronator mass repair for symptomatic medial epicondyle non-unions. Four patients with a mean age of 15 years (range, 11-19 years) diagnosed with symptomatic medial epicondyle nonunions were evaluated. All were treated with medial epicondyle excision with ulnar collateral ligament and flexor-pronator mass repair. Two of the patients were followed for 12 months, whereas the other 2 patients were followed for 18 months. All patients returned to their preinjury level of sports without difficulty. Two patients with preoperative flexion contracture had residual flexion contractures of 4° and 5° postoperatively, respectively, as measured by a goniometer. All other patients regained full elbow motion equal to that of the contralateral extremity at final follow-up. The patients with preoperative ulnar nerve symptoms had complete resolution postoperatively at a mean follow-up of 18 months. In overhead and upper extremity weight-bearing athletes who have symptomatic medial epicondyle nonunions, fragment excision with flexor-pronator mass repair can yield satisfactory results. [Orthopedics. 2021;44(3):e337-e342.].

Fracture of the medial epicondyle is a common pediatric injury, with an estimated annual incidence of 40 to 60 per 100,000 people per year^1-3. Medial epicondylar fractures are associated with elbow dislocation in about 60% of cases, and ulnar nerve dysfunction is reported to occur nearly 10% of the time^2,4. No standard of care for medial epicondylar fracture exists, as similar outcomes have been demonstrated in observational studies with both operative and nonoperative treatment^5,6. Increasingly, however, these injuries are being treated with surgical intervention, which in most cases consists of a single screw affixing the osseous piece back to its donor site on the humerus^7-9. There is broad consensus on the absolute indications for operative treatment, including an open fracture and an incarcerated epicondylar fragment^1,10-13. The relative indications are more controversial and include ulnar nerve dysfunction, elbow instability, increased fragment displacement, and high-level throwing or upper-extremity weight-bearing athletes^2,9,14-16.

The patient is placed in the prone position with the operative arm on a radiolucent arm board. A milking maneuver with an Esmarch bandage is utilized. A posteromedial incision is made over the medial epicondyle. The ulnar nerve is protected posteriorly. The fracture is easily reduced under minimal tension, and then 1 or 2 guidewires from the 4.0-mm cannulated screw kit are placed to fix the fragment. The central guidewire is overreamed, and then a partially threaded 4.0-mm screw is placed in a relative posterior-to-anterior trajectory within the medial column of the elbow.

Nonoperative treatment includes immobilization in a long arm cast until fragment healing. Complications associated with nonoperative treatment include nonunion and late instability. Supine positioning is a reasonable alternative to the prone position described here. In that case, the fracture is fixed with the arm in external rotation of the shoulder and with the elbow extended.

Prone positioning for operative treatment of medial epicondylar fractures is preferred because the tension from the flexor pronator mass associated with supine positioning is negated, facilitating an easier fracture reduction and improved anatomic reduction.

To our knowledge, there are currently no Level-I or Level-II prospective studies reporting on the outcomes of operative versus nonoperative treatment of medial epicondylar fractures. A systematic review of retrospective results suggested no difference in pain or clinical outcomes, but >9-times greater odds of union with operative treatment^5,6. Expectations following operative treatment of a medial epicondylar fracture have been explored in multiple studies. Generally, return to full levels of activity and near-normal range of motion of the elbow have been demonstrated by most. Minor rates of range-of-motion limitation, including extension deficit (4% with deficit up to 20°) are reported in some studies⁸. In the setting of preoperative instability, the expectation is that elbow stability will be achieved by operative treatment^7,8.

Perform and document an accurate preoperative neurovascular examination of the arm.Test the shoulder in internal rotation prior to prone positioning.Protect the ulnar nerve during surgical fixation and drilling.Confirm that the screw trajectory is relatively posterior to anterior and only in the medial column of the elbow.

The objective of the study is to evaluate the natural history of the medial epicondyle avulsion in children with nonoperative treatment (NOPT) on different magnitude of displacement and long-term follow-up. A prospective study of 34 patients with medial epicondyle avulsion with (NOPT) was performed. Clinical test (stability, strength, atrophy, tenderness, Tinel test, and range of motion), subjective scores [Visual Analog Scale (VAS), Likert scale, side-to-side valgus test], and objective four scores were performed. Age at the time of injury was 8.9 ± 2.81 years. Follow-up was 7 ± 2.81 years. Four of the patients had anterior displacement. Displacement varied between 3 and 26 mm (10.49 ± 6.16 mm). Subjective: VAS and ordinal three-point Likert scale were excellent. Objective results were also excellent Mayo Elbow Score: 98.67 ± 4.31 (85-100), Oxford Elbow Score: 59.35 ± 1.68 (51-100), Elbow Assessment Score System: 96.27 ± 9.77 (57-100), Disabilities of the Arm, Shoulder, and Hand (DASH) score 0.64 ± 1.001 (0-4.16). We did not find any differences in strength or forearm diameter. There was an extension deficit in seven cases with a significant association with the magnitude of displacement (P = 0.02) and with the presence of concomitant lesions or anterior displacement of the medial epicondyle >5 mm. All except one were stable clinically on valgus stress. There is a significant association between the objective outcomes (scores) and concomitant lesions but not with regards to the DASH score P = 0.102). There is no association between the magnitude of medial epicondyle displacement or the follow-up and the objective outcomes. Instability was associated with valgus stress activities. There is no association between the magnitude of displacement of the medial epicondyle or the follow-up and the objective outcomes. NOPT produces excellent subjective and objective outcomes that worsened when there were associated lesions, anterior medial epicondyle displacement, or in patients who performed activities with repeated valgus stress. Based on our study, NOPT is suitable except for Open Reduction Internal Fixation indications: absolute indications, high energy injury with associated lesions, medial humeral epicondyle fracture in the dominant elbow in patients subject to activities with chronic valgus stress, and anterior displacement.

Compare outcomes of operative and nonoperatively managed medial epicondyle fractures in upper-extremity athletes.

Retrospective chart review and phone survey.

Level 1, tertiary-referral pediatric hospital.

Propensity scores (probability of operative treatment) were estimated from a logistic regression model that included sex, age, displacement, limb dominance, and injury severity (presence of an additional fracture, nerve injury, or elbow dislocation). These were used to match subjects in the operative group to the nonoperative group.

Return to sport, duration of time required to return to sport, pain, range of motion (ROM), need for physical therapy, and complications were recorded for both groups.

Twenty-eight nonoperative subjects were matched to 14 operative subjects. There was no significant difference in the proportion of subjects who returned to the same sport (92.9% in each group), performance at preinjury level of competition, or median time to return to play (P = 0.7106). There was no significant difference in functional limitations in social-/work-related activities (P > 0.9999), pain in the past 30 days (P = 0.0640), need for physical therapy (P = 0.5680), ROM limitations (P = 0.0988), difficulty in sleeping (P = 0.4773), or complications (P = 0.4081).

Our study found no statistical difference in outcomes or complications between operative and nonoperatively treated moderately displaced medial epicondyle fractures in adolescent upper-extremity athletes. Our data show that similar outcomes may be achieved with both treatment groups for medial epicondyle fractures in upper-extremity athletes.

There remains controversy surrounding the treatment of pediatric medial epicondyle fractures. This systematic review examines the existing literature with the aim to elucidate optimal management strategies.

A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was executed. All data collection was completed by August 01, 2018. Functional outcomes, diagnostic imaging, athlete management, union rates, ulnar nerve symptoms, surgical methods, surgical positioning, and posttreatment protocols were categorized and recorded. Frequency-weighted mean values were calculated with associated SDs.

Thirty-seven studies with 1022 patients met the inclusion criteria. Functional outcomes for patients were mostly good following operative and nonoperative management. The most common complication was a slight loss of elbow extension (7.6±5.9 degrees) and flexion (13.3±5.8 degrees). Operative treatment was associated with higher union rates than nonoperative management (700/725, 96% vs. 69/250, 28%; P<0.001). Standard diagnostic imaging techniques to measure displacement were unreliable with a newly proposed axial view having high inter-rater and intrarater reliability. The most common surgical method used was open reduction and internal fixation with Kirschner wires. Whereas surgical management of patients with associated ulnar nerve symptoms led to symptom resolution, nonoperative management occasionally led to the development of these symptoms. Elbow range of motion was initiated at ~2.8±1.4 (range, 0 to 8 wk) weeks after surgery and 3.4±1.2 (range, 3 to 5 wk) weeks without surgery (P<0.001).

Although there is still no consensus on treatment of pediatric medial epicondyle fractures, both operative and nonoperative approaches result in good outcomes.

Level IV-therapeutic.

In adolescent patients, cannulated lag screw (CLS) is a widely accepted choice for fixation of the medial epicondylar fracture of the humerus (MEFH). Absorbable implants, including rod, screw, and mini-plate, have been reported in children. However, to the best of our understanding, this study is the first head-to-head comparative study of CLS versus bioabsorbable screw (BS) in the treatment of MEFH.Patients of MEFH operated at our institute, from January 2010 to January 2016, were reviewed retrospectively. The patients were divided into 2 groups, the CLS group and the BS group, as per the type of implant the patient received. The CLS group consisted of 35 patients, whereas the BS group consisted of 30 patients. Demographic data, including sex, age at the time of surgery, operated side, and implant material, were collected from the hospital database. Elbow range of motion (ROM), radiographic manifestation was recorded during the out-patient visit. The elbow joint function was evaluated according to the Broberg and Morrey elbow scale and Mayo elbow performance index score.Thirty patients, including 18 males and 12 females, were included in the CLS group, whereas 35 patients, including 21 males and 14 females, were included in the BS group. At 6-month follow-up, elbow range of motion, Broberg and Morrey elbow scale and Mayo elbow performance index scale showed no significant difference between the 2 groups. The carrying angle was within the normal range in both groups. There was no nonunion or malunion in either group. The rate of hypoplasia or hyperplasia was low in both groups, 3.3% in CLS and 2.9% in BS. The rate of implant prominence was significantly higher in the CLS group (33.3%) than BS (0%).Both CLS and BS are safe and effective choices for displaced MEFH in adolescents. The BS can produce a satisfactory clinical outcome and is comparable to the CLS. Besides, the BS has the advantage of not needing second surgery for implant removal.

Medial epicondyle fractures are the 3rd most common pediatric elbow fractures. Regardless of treatment method, some degree of elbow motion loss has been reported. The purpose of our study was to determine the relationship between the amount of anterior fracture displacement and loss of elbow passive extension in an adult cadaveric medial epicondyle fracture model. Fifteen fresh frozen adult cadavers were procured to create fracture models at scenarios of 2, 5, 10 mm, and maximum displacement. Terminal elbow extension was recorded for each cadaveric model at each fracture scenario. A linear mixed model regression analysis was used to test the association between fracture displacement and loss of terminal elbow passive extension. At 2 mm of displacement, the average loss of terminal extension was 3.89°; at 5 mm, it was 7°; at 10 mm, it was 10.7°; at maximum displacement (~15 mm), it was 17°. A statistically significant positive linear association between fracture displacement and loss of terminal elbow extension was observed (5 mm of displacement = loss of ~4.7°). In our fracture model, when the medial epicondyle displaced anteriorly, we noticed a change in the tension of the medial collateral ligaments which lead to a decrease in terminal elbow extension. However, this only contributed partially to the loss of motion observed clinically in the literature. Even though our findings did not support the recommendation of surgical intervention to prevent loss of elbow motion in medial epicondyle fractures, we still encourage physicians to consider the consequence of displacement and its potential influence of elbow range of motion.

The purpose of our study was to compare the treatment outcomes and complications between operatively and nonoperatively treated displaced medial epicondyle fractures. Pediatric patients treated for an acute, displaced medial epicondyle fracture between 2005 and 2015 were retrospectively reviewed. A total of 22 operative participants were matched to 22 nonoperative participants, with an average displacement of 9.7 mm in both groups. There was no statistical difference in average length of immobilization, median time to full pronation/supination and flexion/extension, proportion of patients needing physical therapy, and complications. There were no statistical differences in outcomes between operative and nonoperatively treated, moderately displaced, pediatric medial epicondyle fractures. This suggests that operative and nonoperative interventions show equivalent outcomes for these injuries.

Controversy exists with regard to the amount of fracture displacement that warrants surgical fixation of medial epicondyle fractures. Inaccurate determination of degree of displacement on plain radiographs may account for the disputed management. Recently, a novel distal humerus axial radiograph technique has been developed to improve the accuracy of radiographs. The purposes of the study are 2-fold; to identify the anatomic orientation of the medial elbow epicondyle physis in children and to compare the accuracy of determining fracture displacement between axial radiographs and standard anterior-posterior (AP) radiographs in a cadaveric medial epicondyle fracture model.

Twelve pediatric elbow computed tomographic scans and 19 pediatric elbow magnetic resonance imaging scans were analyzed for the orientation of the medial elbow physis. After determining the correct orientation, 15 adult cadaveric medial epicondyle fracture models were created at displacements of 2, 5, 10 mm, and maximum displacement with elbow at 90 degrees of flexion. A linear mixed model regression analysis was used to compare displacement based on the axial versus the AP radiographic methods.

The medial epicondyle physis was found to be a posterior structure angled distally at ~36 degrees (range, 10.7 to 49.6) and angled posteriorly at 45 degrees (range, 32.2 to 59). The AP radiograph significantly underestimated displacement relative to the axial radiograph at 5 mm [mean difference, -1.6; 95% confidence interval (CI), -2.9 to -0.3], at 10 mm (mean difference, -4.5; 95% CI, -5.8 to -3.2 mm), and at maximal displacement (mean, 15 mm; range, 13 to 20 mm) (mean difference, -7.1; 95% CI, -8.3 to -5.8).

The medial epicondyle physis of the distal humerus is a posterior structure angled distally and posteriorly. When displacement was >5 mm, the distal humerus axial radiograph technique was significantly more accurate than the AP radiograph technique at determining actual fracture displacement in our adult cadaveric fracture models. Therefore, we recommend clinicians to include the axial radiograph view during the evaluation of patients with medial epicondyle fractures.

This study provides further insight into the location and orientation of the medial humeral epicondyle physis, and further supports the improved accuracy of the distal humerus axial radiograph at detecting displacement in medial epicondyle fractures.

This study was conducted to explore epidemiologic features of traumatic elbow dislocation with associated fractures in pediatric population following appropriate treatment options.Incidence of elbow dislocation with associated fractures was analyzed in 67 children using elbow radiographs. Treatment for the displaced elbow joint was performed by closed reduction and proper immobilization. Surgical intervention was applied to restore the correct alignment of the fracture. Mayo Elbow Performance Score (MEPS) was used to measure elbow joint function.Incidence of pure dislocation was observed in 7 of 67 children (10.45%). Elbow dislocation was typically accompanied by a single or multiple fractures in 39 (58.21%) and 21 (31.34%) of 67 children, respectively. In contrast, lateral humeral condyle fracture and medial humeral epicondyle fracture accounted for 35.90% and 30.77% of pediatric elbow fractures. All children with elbow fracture-dislocations received surgical intervention by open reduction and internal fixation. During follow-up, 56% to 92% of children displayed significant recovery of elbow function with improving MEPS after the displaced elbow and fractured fragments were reduced and held in place for weeks. There were statistical differences in MEPS between the types of fractures (P < .05 or P < .01).Incidence of isolated elbow dislocation without fracture is low; rather, it is frequently associated with fractures. Early surgical intervention achieves stable fixation and bony union with utility in improving elbow function in the pediatric population.

Medial epicondyle fractures may occur in isolation or with associated elbow dislocation. In the absence of open fracture or fragment incarceration, nonoperative management with immobilization has been shown to result in generally successfully outcomes comparable with those reported after surgical fixation. However, no comparative investigation has assessed outcomes after nonoperative treatment based on the presence or absence of elbow dislocation.

A systematic review was conducted investigating all studies in the literature reporting nonoperative outcomes for isolated medial epicondyle fractures and fracture-dislocations. Databases included in this review were PubMed, Biosis Preview, SPORTDiscus, PEDro, and EMBASE. We sought to evaluate results related to the incidence and outcomes of bony nonunion and the incidence of elbow stiffness, pain, ulnar neuropathy, cubitus valgus deformity, and laxity between isolated fractures of the medial epicondyle and fracture-dislocations.

Review of the literature yielded 7 studied meeting appropriate inclusion and exclusion criteria, comprising 81 total patients (n=42 patients with fracture-dislocations, n=39 patients with isolated fracture). Bony nonunion occurred in 69% (n=29) of patients with fracture-dislocation versus 49% (n=19) with isolated fractures (P=0.11); however, both groups had minimal clinical or functional disabilities at final follow-up. Decreased elbow flexion and extension range of motion were significantly more frequent after fracture-dislocation than isolated fractures [43% (n=18) vs. 15% (n=6), respectively, P=0.01], while patients rarely demonstrated pain, ulnar neuropathy, or deformity in the presence or absence of dislocation.

In the absence of absolute surgical indication, nonoperative management of isolated medical epicondyle fractures with or without concomitant elbow dislocation seems to be successful with few long-term complications leading to functional disability. However, increased rates of nonunion, elbow stiffness, and elbow laxity may occur with fracture-dislocations, and merit further study with validated functional outcome scores. Further comparative studies are necessary to determine the true indications and outcomes in nonoperatively managed medial epicondyle fractures.

Level II-systematic review of level-II or level-I studies with inconsistent results.

The medial epicondyle serves as the proximal attachment of the medial ulnar collateral ligament and the origin of the flexor pronator musculature and as such it is responsible for resisting the main static and dynamic restraints to valgus force at the elbow. Fractures through the physis in the developing elbow are common and treatment remains controversial. Biomechanical modeling predicts that anterior should be the direction of greatest displacement. Anatomic considerations predict that anterior displacement should have the greatest effect on elbow stability and range of motion making the ulnar collateral ligament too loose in flexion and too tight in extension and potentially leading to valgus laxity in flexion and a block to full extension. In the elite overhead athlete, where elbow stability is critical both for sports performance and the long-term health of the elbow, assessment of anterior displacement is thus theoretically an important consideration. Standard radiographic views cannot adequately assess anterior displacement. Specialized radiographs and 3-dimensional modalities such as computerized tomography and magnetic resonance imaging can adequately assess anterior displacement and in the overhead athlete can sometimes aid in the decision-making process. Here, we present a review of the current literature and the rationale for a treatment algorithm for medial epicondyle fractures in the skeletally immature overhead athlete.

In caring for athletes, the physician must be able to accurately diagnose and appropriately treat all forms of elbow injuries. Traumatic injuries to the elbow are common in the athlete. The late cocking phase of throwing produces tremendous valgus stress on the elbow that can lead to medial epicondyle avulsion fractures in adolescents or rupture of the medial ulnar collateral ligament in skeletally mature overhead throwers, such as baseball pitchers and javelin throwers. Common traumatic elbow injuries suffered by athletes, surgical techniques for operative repair of these injuries, as well as postoperative rehabilitation protocols and the clinical results are presented.

This study explores the change in the position of the fragment in isolated, displaced, medial humeral epicondyle fractures in children. In this series, 34 patients (mean age 11.0 years) were treated nonoperatively by cast immobilization with no attempt at closed fracture reduction. A statistically significant association was found between the position of the fracture fragment at the time of initial fracture compared with 3 weeks after fracture (P=0.015). Twenty-six of 34 patients (76.5%) showed spontaneous improvement in fragment position. These findings support the practice of treating significantly displaced medial epicondyle fractures nonoperatively.

The present review discusses the relevant anatomy, clinical presentation, and management of medial epicondyle fractures, including diagnostic controversies, the indications for operative and nonoperative management, and outcomes.

Recent studies have highlighted the underestimation of fracture displacement seen on typical radiographic views and have attempted to define the location of the medial epicondyle on radiographs to improve the accuracy of measuring displacement. They have demonstrated variable outcomes following open reduction and internal fixation of medial epicondyle fractures that are associated with intra-articular incarceration. Newer evidence supports the fixation of medial epicondyle fractures in adolescent athletes, to allow return to competitive sports.

Medial epicondyle fractures of the distal humerus account for 12% of pediatric elbow fractures and are frequently associated with intra-articular incarceration of the fracture fragment, elbow dislocation, ulnar nerve injury, and other upper extremity fractures. Recent literature calls into question the accuracy of measuring fracture displacement, and controversy exists regarding optimal management of these fractures. Good outcomes have been achieved with nonoperative treatment for minimally displaced fractures, despite a high rate of nonunion. In patients with displaced fractures, fixation yields stability, functional range of motion, and the ability to return to previous activity levels, including sports. Complications include stiffness, instability, deformity, superficial wound infections, and symptomatic nonunion. Further study is required to standardize the measurement of displacement and to clarify indications for operative treatment in both sedentary and active children.

Almost 20 % of all long bone fractures in childhood and adolescents involve the elbow region. Physicians dealing with pediatric trauma cases on a regular basis must be familiar with the specific radiologic features of the elbow at every developmental stage. This includes the shape and the appearance of elbow ossification centers, and knowledge of age-specific injury patterns. In young children, lateral condyle and supracondylar fractures of the distal humerus are most common. Radial neck fractures, Monteggia's lesion and olecranon fractures appear in every age during growth. Bicondylar fractures of the distal humerus, capitellar fractures and radial head fractures almost solely occur after the tenth year. Treatment options depend on fracture type, age and demands and vary from immobilization to closed reduction and open reduction including internal fixation with different types of materials. Special circumstances to influence the treatment regimen in every single injury entity are discussed. Additionally, the most common malformations and nontraumatic diseases of the elbow region are mentioned.

The optimal treatment of medial epicondyle fractures in pediatric athletes remains unclear.

To evaluate the outcomes of operative and nonoperative management of medial epicondyle fractures in young athletes.

Case series; Level of evidence, 4.

The records of all children with fractures of the medial epicondyle over a 5-year period, with a minimum 2 years of follow-up at a pediatric tertiary referral center, were reviewed. Patients with intra-articular entrapment of the fracture fragment or ulnar nerve entrapment were excluded. Treatment decisions were made primarily based on injury mechanism and elbow laxity or instability. Patients were contacted and asked to complete a modified Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

Complete data with 2-year follow-up were available for 20 athletes: 6 treated nonoperatively and 14 treated operatively. At the latest follow-up, both groups achieved excellent DASH scores. Half of each cohort required physical therapy, and 6 of 14 patients who received operative treatment reported numbness. All patients were either very or completely satisfied with their treatment. Fourteen patients were overhead athletes (8 treated operatively, 6 nonoperatively). Excellent DASH scores were achieved in both groups, and all overhead athletes were able to return to their sport at the next appropriate level. Seven patients were baseball pitchers and sustained a fracture while throwing (4 treated operatively, 3 nonoperatively). None felt their performance was limited after treatment, and excellent DASH scores were achieved in both groups.

These data demonstrate that nonoperative treatment can be successful in young athletes with low-energy medial epicondyle avulsions, a stable elbow, and minimal fracture displacement. Surgical management can be successful in athletes who sustain more significant trauma, who have elbow laxity or instability, or who have significant fracture fragment displacement after a fracture of the medial epicondyle.

Displaced medial epicondyle fractures are common injuries encountered in pediatric orthopaedic practice. Many practitioners have successful personal experience treating these fractures through nonoperative and operative techniques. This article discusses evidence-based medicine principles related to medial epicondyle fractures. There is a dearth of high-level evidence, and yet we are constantly faced with the need for clinical decision making in the face of uncertainty. Although highly susceptible to bias, pertinent background information (current pediatric fracture textbooks) and meta-analysis of clinical research with a particular focus on harm (and number needed to harm) support surgical recommendations for most patients.

The fundamental principles of fracture care apply to medial epicondyle fractures in that the goals of treatment are to obtain fracture healing and to promote a return of appropriate motion, strength, and stability. Recent studies have revealed limitations of some classically described evaluation methods and have revealed more precise methods of measuring displacement. The authors of this manuscript describe established principles of care and incorporate recent evidence-based articles to help the clinician study the issues relative to the clinical evaluation and the operative and nonoperative treatment of medial epicondyle fractures.

Humeral medial epicondyle fractures in the pediatric population account for up to 20% of elbow fractures, 60% of which are associated with elbow dislocation. Isolated injuries can occur from either direct trauma or avulsion. Medial epicondyle fractures also occur in combination with elbow dislocations. Traditional management by cast immobilization increasingly is being replaced with early fixation and mobilization. Relative indications for surgical fixation include ulnar nerve entrapment, gross elbow instability, and fractures in athletic or other patients who require high-demand upper extremity function. Absolute indications for surgical intervention are an incarcerated fragment in the joint or open fractures. Radiographic assessment of these injuries and their true degree of displacement remain controversial.

There is ongoing debate about the management of medial epicondyle fractures in the pediatric population. This systematic review evaluated non-operative versus operative treatment of medial epicondyle fractures in pediatric and adolescent patients over the last six decades.

A systematic review of the available literature was performed. Frequency-weighted mean union times were used to compare union rates for closed versus open treatments. Moreover, functional outcomes and range-of-motion variables were correlated with varying treatment modalities. Any complications, including ulnar nerve symptoms, pain, instability, infection, and residual deformity, were cataloged.

Fourteen studies, encompassing 498 patients, met the inclusion/exclusion criteria. There were 261 males and 132 female patients; the frequency-weighted average age was 11.93 years. The follow-up range was 6-216 months. Under the cumulative random effects model, the odds of union with operative fixation was 9.33 times the odds of union with non-operative treatment (P < 0.0001). There was no significant difference between operative and non-operative treatments in terms of pain at final follow-up (P = 0.73) or ulnar nerve symptoms (P = 0.412).

Operative treatment affords a significantly higher union rate over the non-operative management of medial epicondyle fractures. There was no difference in pain at final follow-up between operative and non-operative treatments. As surgical indications evolve, and the functional demands of pediatric patients increase, surgical fixation should be strongly considered to achieve stable fixation and bony union.