Long-term results of treatment of fractures of the medial humeral epicondyle in children

Background: The treatment of isolated, displaced fractures of the medial humeral epicondyle in children is controversial. Both plaster cast immobilization without reduction and open reduction and internal fixation have been advocated. The purpose of this long-term retrospective study was to analyze the functional and radiographic results of both nonsurgical and surgical management of these injuries. Methods: Forty-two patients who had had an isolated fracture of the medial humeral epicondyle with displacement of >5 mm at an average age of twelve years (range, eight to fifteen years) were evaluated at an average age of forty-five years (range, thirty to sixty-one years). The patients were divided into three groups that were comparable with regard to the amount of fracture displacement, age at the time of the fracture, age at the time of follow-up, sports activities and occupation, and duration of follow-up. In Group I (nineteen patients), the fracture had been treated with a long-arm plaster cast without reduction of the displaced medial epicondyle. In Group II (seventeen patients), open reduction and internal fixation with either Kirschner wires or a T-nail had been performed. In Group III (six patients), the epicondylar fragment had been excised with suture reattachment of the tendons and the medial collateral ligament. Results: According to a functional grading scale, there were sixteen good and three fair results in Group I. All but two patients were seen to have nonunion of the fragment on follow-up radiographs, but all had a normal result on valgus stress-testing of the elbow. The range of motion of the elbow was either normal or minimally decreased, and the grip strength of the ipsilateral hand was normal. There were fifteen good and two fair results in Group II. All patients had union of the medial epicondyle, with various radiographic deformities of the medial epicondyle, but the functional results were similar to those of the Group-I patients. The Group-III patients had four poor and two fair results. Four had constant pain at the elbow and paresthesias in the distribution of the ulnar nerve. One patient had a restricted range of motion of the elbow, four patients had an unstable elbow, and three patients had decreased grip strength of the ipsilateral hand. Conclusions: In our study, nonsurgical treatment of isolated fractures of the medial humeral epicondyle with between 5 and 15 mm of displacement yielded good long-term results similar to those obtained with open reduction and internal fixation. The nonunion of the epicondylar fragment that was present in most patients who had been treated only with a cast did not adversely affect the functional results. Surgical excision of the medial epicondylar fragment should be avoided because the long-term results are poor.