The treatment of isolated, displaced fractures of the medial humeral epicondyle is controversial. The authors from the University of Rome, Italy, performed a long-term (average 34 years), retrospective outcome study of 42 children treated at La Sapienza from 1950 to 1980 with medial humeral epicondyle fractures displaced more than 5mm but not having entrapment within the joint, ulnar nerve entrapment, or marked elbow instability, all 3 of which were surgical indications. Nineteen patients were treated with 4 weeks of cast immobilization; 17 patients underwent open reduction and internal fixation (ORIF); and 6 patients had excision of the medial epicondyle. Outcome status was based on symptoms, strength, stability, and radiographic assessment of osteoarthritis. To be considered a good result required the following: no symptoms, <10 degrees loss of elbow motion, a negative valgus stress test of the elbow, no atrophy or <1 cm of atrophy, strength greater than or equal to the opposite hand if the injury was to the dominant hand and <3% less strength than the opposite hand if the injury was to the non-dominant hand, and no radiographic signs of osteoarthritis.
Patients treated with cast immobilization and ORIF had equally good functional results. Seventeen of 19 patients treated with cast alone had asymptomatic non-union of the medial epicondyle. None had valgus laxity to stress testing. All patients treated by ORIF had union of the medial epicondyle, but demonstrated radiographic deformity of the epicondyle. Patients treated with excision of the epicondyle had significantly worse results related to pain, limitation of motion, ulnar nerve symptoms, instability of the elbow, or diminished grip strength.
Long-term follow-up studies remain the standard for guiding much of the practice of medicine and surgery, particularly in conditions where problems may take decades to manifest themselves. All such studies have limitations as does this study. There is the possibility of a selection bias in the choice of treatment based on injury characteristics that are not reflected in the medical record and in unblinded assessment of outcomes. The different treatment groups (especially the “excision” group) are small. It is well known that medial humeral epicondyle fractures often accompany elbow dislocations that may spontaneously reduce. Inclusion of more missed elbow dislocations in one of these small groups could significantly bias the results. Nonetheless, the results of non-operative treatment of severely displaced (5 to 15mm) medial epicondyle fractures are clearly very good in the long term. Some practitioners believe that a non-union of the medial epicondyle will result in laxity of the elbow in young athletes involved in throwing sports or gymnastics.1
This study casts a new light on what approach should be taken for the treatment of fractures of the medial epicondyle in children. Despite some of the biases noted by Dr. Dietz, non-operative management may be a suitable alternative to surgical repair assuming that subsequent, larger...