Review Question - QID 220052

This patient previously sustained a right medial epicondyle fracture 8 weeks ago, which was treated nonoperatively with immobilization in a cast. It appears to have progressed to a radiographic nonunion, of which the majority are asymptomatic (Answer 1).

Medial epicondyle fractures are the third most common elbow fracture seen in children, usually occurring in boys between the ages of 9 and 14 years old. Usually resulting from an avulsion-type mechanism, these may be associated with a concomitant elbow dislocation, putting the avulsed fragment at risk of entrapment within the elbow joint itself. While entrapped fragments and open fractures are absolute indications for operative intervention, the treatment of closed, non-entrapped fractures remains controversial. Relative indications for surgery include fragment displacement greater than 2 to 15 mm, greater than 2- to 5-mm displacement in valgus stress in throwers/gymnasts, and ulnar nerve dysfunction. Surgical management has been shown to have an increased rate of radiographic union, but this has not been shown to necessarily affect long-term outcomes. Two randomized clinical trials, the SCIENCE trial (UK, Australia, New Zealand), and the COMET trial (USA, Canada) are currently underway to evaluate patient-reported outcomes, pain, return to sporting activities, complications, cost-effectiveness, and satisfaction following nonoperative versus operative treatment of these fractures.

Kamath et al. published a 2009 systematic review on the outcomes following nonoperative and operative treatment for medial epicondyle fractures. The authors reviewed 14 studies and recorded the incidences of bony union, pain, and a host of complications, including ulnar nerve symptoms, range of motion restriction, and deformity. The authors noted no significant differences in pain or other complications between operative and nonoperative treatments, although there was a statistically significantly higher rate of radiographic union with operative treatment.

Lawrence et al. published a 2013 case series evaluating the outcomes of operative and nonoperative management of medial epicondyle fractures in young athletes. Records of all children with fractures of the medial epicondyle over a 5-year period, with a minimum of 2 years of follow-up at a pediatric tertiary referral center, were reviewed. The authors concluded 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.

Axibal et al. published a 2020 retrospective study evaluating the outcomes of operative and nonoperatively managed medial epicondyle fractures in upper-extremity pediatric athletes. 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 28 nonoperative subjects matched to 14 operative subjects. The study found no statistical difference in outcomes or complications between operative and nonoperatively treated moderately displaced medial epicondyle fractures in adolescent upper-extremity athletes.

Figure A consists of AP and lateral radiographs demonstrating a medial epicondyle fracture nonunion.

Incorrect Answers:
Answer 2-5: The majority of medial epicondyle nonunions are asymptomatic.