Pediatric Medial Epicondyle Fractures: To Fix or Not To Fix?

Pediatric medial epicondyle fractures are common elbow injuries that represent an avulsion fracture of the apophysis. These fractures are commonly associated with elbow dislocation, and as such, acknowledging the soft-tissue injury and resultant potential elbow instability is important. Treatment decision making is controversial because few absolute indications for surgery exist, and no true displacement cutoffs have been settled despite plentiful research. Although fracture incarceration in the joint, open fractures, ulnar nerve entrapment, and frank elbow instability are indications for surgery, fracture displacement is not a set tolerance. As patient expectations and activities have evolved with time, so have surgical techniques and the understanding of weighing risks and benefits of surgery. Fractures with less than 2 mm displacement are commonly treated with casting only, fractures with 2 to 15 mm displacement have been shown to represent a gray zone that may be indicated for surgery, and fractures with greater than 15 mm displacement are commonly recommended for surgery. Fixation strategies include pin fixation, screw fixation with or without a washer, and more recently suture anchors. As more fractures undergo surgical fixation, the understanding of patient outcomes, surgical risks including nonunion, and revision tactics will continue to expand.