Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures

Background and purpose — Controversy exists regarding the optimal treatment for displaced medial epicondyle fractures. We compared the results of nonoperative and operative treatment and calculated the incidence of medial epicondyle fractures in the pediatric census population.Patients and methods — 112 children under 16 years old who sustained > 2 mm displaced fracture of the medial epicondyle were treated in our institution between 2014 and 2019. 80/83 patients with 81 non-incarcerated fractures were available for minimum 1-year follow-up. 41 fractures were treated with immobilization only, 40 by open reduction and internal fixation, according to the preference of the attending surgeon. Outcome was assessed at mean 2.6 years (1–6) from injury with different patient-reported outcome measures. Elbow stability, range of motion, grip strength, and distal sensation were registered in 74/80 patients. Incidence was calculated for 7- to 15-year-olds.Results — Nonoperatively treated children had less pain according to the PedsQL Pediatric Pain Questionnaire (3 vs. 15, p = 0.01) with better cosmetic outcome (VAS 95 vs. 87, p = 0.007). There was no statistically significant difference between the groups in respect of QuickDASH, PedsQL generic core scale, Mayo Elbow Performance Score, grip strength, carrying angle, elbow stability, or range of motion (p > 0.05). All 41 nonoperatively treated children returned to pre-injury sports; of the surgically treated 6/40 had to down-scale their sporting activities. The incidence of displaced (> 2 mm) fractures of the medial epicondyle in children aged 7–15 years was ≥ 3:100,000.Interpretation — Displaced fractures of the medial humeral epicondyle in children heal well with 3–4 weeks’ immobilization. Open reduction and screw fixation does not improve outcome.

Fractures of the medial humeral epicondyle have been reported to account for 12–20% of all pediatric elbow fractures, but the incidence is not known. Elbow dislocation is associated with 30–50% of these fractures (Gottschalk et al. 2012), with an incarceration rate of the fracture fragment into the elbow joint of 5–18%. Ulnar nerve lesions are registered in 10–16% of cases (Louhaem et al. 2010).Nonoperative treatment is advised in minimally displaced (< 2 mm) fractures of the medial humeral epicondyle, whereas surgery is recommended for fractures incarcerated in the elbow joint as well as for fractures that are either grossly unstable or where the ulnar nerve is entrapped (Smith 1950, Blount 1955, Maylahn and Fahey 1958, Bede et al. 1975, Gottschalk et al. 2012, Tarollo et al. 2015). Significant controversy concerning the treatment of displaced (3–15 mm) fractures exists, with some surgeons advocating early mobilization, some immobilization, and some internal fixation (Lee et al. 2005, Hughes et al. 2019, Pezzutti et al. 2020). It has also been suggested that competitive athletes or fractures occurring in combination with elbow dislocation should be treated surgically with a lower threshold than in children without sporting activities (Baety and Kasser 2014).The reported outcome of nonoperative and operative treatment in displaced fractures of the medial humeral epicondyle in terms of elbow function and complications has been similar (Farsetti et al. 2001, Biggers et al. 2015, Axibal et al. 2019).We compared subjective and objective outcomes and calculated the incidence of medial humeral epicondyle fractures in children treated either with immobilization or with open reduction and internal fixation (ORIF).