Medial Epicondyle Fractures in Children

Classification by Displacement

There is no universally accepted classification. Commonly described by displacement:

Note: The 5mm threshold has been historically used for surgical decision-making but is increasingly controversial. Many centers report good outcomes with conservative treatment up to 10-15mm.

Associated Injury Classification

Describing the clinical context is important:

• Isolated: Medial epicondyle fracture only
• With elbow dislocation: 50% of cases - higher risk of incarceration
• With other elbow fracture: Olecranon, coronoid, radial head/neck

Associated elbow dislocation affects outcomes and treatment decisions.

Non-Operative Management

Indications:

• Minimally displaced fractures (less than 5mm)
• No fragment incarceration
• Non-throwing athlete or low-demand patient
• Intact ulnar nerve function
• Joint congruent

Protocol:

1. Above-elbow splint or cast with elbow at 90°, forearm neutral
2. Duration: 1-2 weeks immobilization
3. Then begin progressive ROM exercises
4. Avoid valgus stress for 6 weeks
5. Return to throwing: 8-12 weeks, gradual progression

Expected Outcomes:

• Good functional outcomes in most cases
• Fibrous union common (not bony) but this is functionally acceptable
• Low rates of symptomatic non-union

Even up to 10-15mm displacement, some centers report excellent outcomes with conservative treatment.

Operative Management

Absolute Indications:

• Incarcerated fragment in joint (mandatory)
• Open fracture

Relative Indications:

• Displacement greater than 5mm (controversial - some use 10mm)
• High-level throwing athlete
• Ulnar nerve dysfunction
• Valgus instability
• Associated elbow instability

Surgical Options:

Post-operative:

• Splint for 2-4 weeks
• Progressive ROM
• Avoid valgus stress 6-8 weeks
• Return to throwing 3-4 months

Surgery provides anatomic restoration but has similar long-term outcomes to conservative treatment in many studies.

ORIF with Cannulated Screw

Standard technique for pediatric medial epicondyle fractures with adequate fragment size.

Technical Points:

• Screw should be parallel or slightly posterior to avoid articular surface
• Partially threaded screw for compression
• Washer optional if bone is soft
• K-wires may be preferred in younger children or small fragments

Ulnar nerve transposition is rarely needed but may be done if nerve is subluxating or injured.

Extraction of Incarcerated Fragment

Mandatory step before ORIF when fragment is trapped in joint.

Technique:

1. Medial approach with gentle distraction of joint
2. Identify fragment in ulnohumeral joint (usually posteromedial)
3. Extract fragment with soft tissue attachments intact (flexor-pronator, UCL)
4. Irrigate joint thoroughly
5. Reduce fragment to epicondyle bed
6. Fix with screw or K-wires as above

Key Points:

• Fragment may have periosteal attachments to bone bed
• Do not use lateral approach through joint - risks iatrogenic injury
• If fragment is comminuted or very small, excision with soft tissue repair may be needed (rare)

Post-extraction, proceed to standard ORIF technique.