Outcomes in Operative vs Non-Operative Management of Pediatric Medial Epicondylar Fractures

Background/Purpose: Medial epicondylar fractures are one of the most common pediatric elbow fractures and require operative treatment in close to 50% of cases. Due to growing uncertainty surrounding displacement measurements, concerns for athletes who demand a high level of upper extremity function and efforts to avoid valgus instability resulting from non-union, there has been an increase in operative intervention for these fractures in the past decade. Our study sought to compare outcomes between medial epicondylar fractures treated operatively and non-operatively. Methods: Pediatric patients presenting at a large, tertiary pediatric hospital between 2007 and 2017 with isolated medial epicondyle fracture, including those with associated dislocations, were identified and retrospectively reviewed. Patients were separated into two groups based on treatment method (no reduction or closed reduction with cast immobilization versus operative open reduction with internal fixation (ORIF)). Outcomes assessed in each group included problems with union, early stiffness (>30-degree lack of flexion or extension measured within 4 to 6 weeks post-injury), persistent stiffness (>10-degree lack of flexion or extension measured within 2 to 4 months post-injury) and long-term complaints of pain. Analysis of outcome with regard to treatment method was performed using Pearson’s chi-square tests. Results: The non-operative group included 109 patients and operative group included 91 patients. Problems with union occurred exclusively in the non-operative group. 8 patients experienced nonunion, 3 of which eventually required delayed ORIF. 46% of patients in both groups experienced early stiffness. 36% of patients in the operative group experienced persistent stiffness compared to 18% in the non-operative group, X2 (1, N=200) =7.27, p=0.0070. The operative group experienced higher rates of pain (25%) compared to 12% of patients in the non-operative group, X2 (1, N=200) =6.99, p=0.0082. These complaints notably included 22 patients with hardware associated pain and 8 with ulnar nerve symptoms. 30.7% of patients in the operative group required re-operation, 27 for hardware removal, and 2 for ulnar nerve transposition. Furthermore, both groups each had 5 patients who experienced injuries associated with throwing years later (medial epicondylitis or UCL sprain). Conclusions: Operative treatment is associated with excellent outcomes in regard to union, but perhaps at the expense of hardware associated complications such as pain and the need for operative removal. Consideration of athletes demanding high range of motion and elbow stability has contributed to the increase in operative fixation, but data to support this indication remains scarce. Our study actually demonstrated higher rates of persistent stiffness in patients treated operatively, contrary to what has been previously theorized. As the management of these fractures remains a topic of debate, it is important for clinicians to recognize the nuances of outcomes associated with each management strategy to better guide discussions surrounding treatment decisions.