What is the treatment for a medial epicondyle chip fracture?

Treatment of Medial Epicondyle Chip Fracture

For nondisplaced medial epicondyle chip fractures, immobilization with a posterior splint is the recommended treatment, providing superior pain relief compared to other immobilization methods. 1

Initial Management Based on Displacement

Nondisplaced Fractures

• Posterior splinting provides the best pain control within the first 2 weeks after injury, supported by randomized controlled trial evidence comparing it to collar and cuff immobilization 2, 1
• Rigid immobilization with a posterior splint provides adequate stabilization while allowing appropriate healing 1
• Immobilization should typically continue for ≥4 weeks when treating nonoperatively 3
• Regular radiographic follow-up is essential to monitor healing and detect any late displacement 1

Displaced Fractures - Surgical Indications

Absolute indications for operative treatment:

• Open fracture 4
• Incarcerated epicondylar fragment within the joint 4

Relative indications for operative treatment:

• Ulnar nerve dysfunction 4
• Elbow instability 4
• Fragment displacement >5-10 mm (surgeon-dependent threshold, with 80.4% of surgeons considering displacement amount in their decision) 3
• High-level throwing athletes or upper-extremity weight-bearing athletes 4

Surgical Technique When Indicated

Open reduction and internal fixation (ORIF) with screw fixation is the standard surgical approach when operative treatment is chosen 4, 5:

• Single 4.0-mm partially threaded cannulated screw is typically used to fix the fragment back to the donor site 4
• Prone positioning is preferred over supine because it negates tension from the flexor-pronator mass, facilitating easier reduction 4
• The ulnar nerve must be identified and protected during the procedure 4
• Screw trajectory should be relatively posterior-to-anterior within the medial column only 4
• Post-operative immobilization is typically ≤2 weeks (81.9% of surgeons recommend this duration) 3

Expected Outcomes and Complications

Operative treatment outcomes:

• Excellent long-term clinical outcomes with mean PROMIS Upper Extremity score of 56.9 at average 6.3-year follow-up 5

• 9-times greater odds of achieving union compared to nonoperative treatment 4

• Return to full activity levels and near-normal elbow range of motion in most patients 4
• 41% require secondary surgery for symptomatic hardware removal 5
• 18% develop sensory ulnar nerve complaints, 5% develop motor complaints 5
• Minor extension deficits (up to 20°) occur in 4% of cases 4

Nonoperative treatment outcomes:

• Similar pain and clinical outcomes to operative treatment in retrospective studies 4
• Risk of nonunion and late instability 4

Clinical Decision-Making

Factors influencing treatment choice (based on surgeon survey data) 3:

• Chronological/skeletal age (64.2% consider this)
• History of elbow dislocation (74.1% consider this)
• Neurovascular status (65.3% consider this)
• Amount of fragment displacement (80.4% consider this)

No standardized consensus exists for treatment approach, with significant practice variation among pediatric orthopedic surgeons, particularly for fractures with 5-10 mm displacement 3. The decision remains multifactorial, weighing displacement, patient age, activity level, and associated injuries.