Operative versus non-operative management of pediatric medial epicondyle fractures: A systematic review

Abstract

PurposeThere 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.MethodsA 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.ResultsFourteen 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).ConclusionsOperative 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.

Optimal management of physeal elbow injuries in the skeletally immature athlete remains undefined: a systematic review

“…Non-operative measures commonly produce satisfactory results and return to play 1–3 6 18 19 24 26–30. However, despite evidence of satisfactory results of non-operative treatment, there has been an increasing trend in operative treatment for physeal elbow injury 31. Particularly for athletes, there remains a theoretical advantage of operative management in achieving bony union, given the heavy demand on the dominant elbow 31.…”

Fixation of Displaced Medial Epicondyle Fractures in Adolescents

“…The benefits include early postoperative range of motion, early return to sports, 100% union rate, and excellent recovery of preoperative range of motion. 1,7 Theoretically, the washer increases the surface area for compression, improves stability, and prevents the screw head from penetrating or fragmenting the apophyseal epicondyle fragment. However, adding the washer also prevents the ability of the surgeon to bury the screw head, which can be done in the absence of the washer, potentially leading to hardware prominence.…”

“…1 The treatment of displaced medial epicondyle fractures in children remains controversial due to the lack of high-level evidence, however, good results have been reported with both operative and nonoperative management. [2][3][4][5][6][7][8][9][10][11][12] For elbows that are treated surgically, the goal is to achieve anatomic reduction with adequate fracture fixation to allow for early postoperative mobilization to minimize postoperative stiffness.…”

Functional Loss With Displacement of Medial Epicondyle Humerus Fractures

“…1,2 There are absolute indications for operative management, including an open fracture or an entrapped intra-articular fragment, 3,4 as well as relative indications, including: valgus instability, ulnar neuritis, and various amounts of fragment displacement. 5 The hypothesis for recommending surgery when a fragment is displaced is that a displaced fragment may result in pain, instability, nonunion, and muscle weakness. 3,4 Historical publications over the past 50 years have suggested that the primary displacement vector is medial, as measured on the anteroposterior (AP) radiographs, 1-8 and many authors have proposed a variety of thresholds for acceptable measures, ranging from 2 mm to 2 cm of medial displacement.…”

“…3,4 Historical publications over the past 50 years have suggested that the primary displacement vector is medial, as measured on the anteroposterior (AP) radiographs, 1-8 and many authors have proposed a variety of thresholds for acceptable measures, ranging from 2 mm to 2 cm of medial displacement. [3][4][5] However, it is unclear whether AP radiographs measuring medial displacement are accurate reflections of the true anatomic fragment displacement. Interobserver agreement for measurements of medial displacement is only 46%.…”