Journal of Pediatric Orthopaedics - 2026-09-01 - Journal Article; Systematic Review; Comparative Study
Surgical Versus Nonsurgical Management of Pediatric Medial Epicondyle Fractures: An Updated Systematic Review.
Benaroch LR, Anderson RJ, Di Iorio D, Jin W, Bartley D, Carey T, Thornley P
Topics
Key Takeaway
In 1,372 pediatric medial epicondyle fractures, nonoperative management carried a 29.9% nonunion rate but MEPS of 98.6, while operative management yielded 6.4% ulnar nerve symptoms, 13% secondary surgery rate, and MEPS of 95.2.
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Summary
This PRISMA-compliant systematic review queried literature from January 2019 to August 2025 to compare operative (n=1,195) versus nonoperative (n=177) outcomes for pediatric medial epicondyle fractures. Nonoperative treatment produced a 29.9% nonunion rate and 5.6% stiffness rate, while operative treatment produced 6.4% ulnar nerve symptoms and 13% secondary surgery rate. Functional outcomes were excellent in both groups, with frequency-weighted MEPS of 95.2 (operative) versus 98.6 (nonoperative), and 4 of 5 direct comparative studies found no significant ROM difference at final follow-up.
Key Limitation
The 6.7:1 operative-to-nonoperative patient ratio, driven by selection bias in included studies, makes any direct outcome comparison between treatment groups statistically invalid.
Original Abstract
BACKGROUND
There remains a lack of consensus regarding optimal management of pediatric medial epicondyle fractures (MEF). This updated systematic review analyzes the outcomes of operative and nonoperative treatment of MEF to determine the effectiveness of each approach.
METHODS
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to query studies published between January 2019 and August 2025. All relevant outcome data were extracted. Frequency-weighted mean values with SD for commonly reported outcomes were calculated to demonstrate general trends across studies.
RESULTS
Eighteen studies with 1372 patients meeting inclusion criteria were included. In total, 1195 patients were treated operatively, with 177 treated nonoperatively. In nonoperative patients, the most common complications were nonunion (N=53, 29.9%) and range of motion loss/stiffness (N=10, 5.6%). The most common complications in surgical patients included ulnar nerve symptoms (N=76, 6.4%) and range of motion loss/stiffness (N=52, 4.4%). Secondary surgery due to complications occurred in 152 operative cases (13%). Four operative studies (N=245) reported ROM (flexion) numerically, resulting in a frequency-weighted average score of 133.2±12.7 degrees. Three operative studies (N=219) reported ROM (extension deficit) numerically, with a frequency-weighted average score of -1.74±5.8 degrees. Five studies directly compared ROM in operative versus nonoperative patients, with 4 finding no significant differences at final follow-up. Six studies (N=357) reported MEPS values for operative patients, resulting in a weighted mean average of 95.2±6.0. Three studies (N=110) reported MEPS values for nonoperative patients, resulting in a weighted mean average of 98.6±0.7.
CONCLUSIONS
There continues to be no consensus on optimal management of isolated MEFs in pediatric patients though a recent trend in the literature towards more operative management. Each approach carries its own unique risks, though complications are infrequent. In general, functional outcomes were excellent in both surgically and nonsurgically managed patients, reflected in MEPS scores and ROM, among other measures.
LEVEL OF EVIDENCE
Level III-systematic review.