What is the initial treatment for a mildly displaced chip fracture of the medial epicondyle of the elbow in a patient with no signs of neurovascular compromise, significant instability, or open fracture?

Treatment of Mildly Displaced Chip Fracture of Medial Epicondyle of Elbow

For a mildly displaced chip fracture of the medial epicondyle without neurovascular compromise or instability, initial treatment should consist of immobilization with a posterior splint or long arm cast for 3-4 weeks, followed by early mobilization. 1

Initial Management Approach

Immobilization Strategy

• Use a posterior splint (back-slab) or long arm cast as the primary immobilization method, as this provides superior pain relief within the first 2 weeks compared to collar-and-cuff immobilization 1
• Immobilize the elbow at approximately 90 degrees of flexion with the forearm in neutral rotation 1
• Continue immobilization for 3-4 weeks until early fracture healing is evident 1

Key Clinical Considerations

The critical decision point is determining true displacement and elbow stability, not just the millimeters of fragment displacement visible on radiographs. 2

• Perform initial radiographs (AP, lateral, and oblique views) to assess fracture displacement and rule out intra-articular fragment incarceration 1
• Document baseline neurovascular examination, particularly ulnar nerve function, as ulnar neuropathy occurs in approximately 10% of medial epicondyle fractures 3
• Assess for associated elbow dislocation, which occurs in 30-55% of medial epicondyle fractures and may influence treatment decisions 4, 5

Nonoperative Treatment Rationale

For minimally displaced fractures (<5mm displacement), nonoperative management yields excellent functional outcomes despite frequent fibrous union. 6, 5

• Studies demonstrate that 49-69% of nonoperatively treated medial epicondyle fractures result in fibrous (rather than bony) union, yet patients maintain good functional outcomes with minimal pain or disability 6, 5
• Even severely displaced fractures (mean 10mm) managed nonoperatively can achieve good functional results, though they demonstrate residual ulnar collateral ligament laxity 6
• Range of motion typically returns to near-normal in most patients, with only 15% of isolated fractures showing decreased flexion/extension at final follow-up 5

Follow-up Protocol

• Obtain repeat radiographs at 1-2 weeks to ensure no interval displacement 1
• Continue radiographic monitoring at 3 weeks and at cessation of immobilization 1
• Begin gentle range-of-motion exercises after 3-4 weeks of immobilization once early healing is confirmed 1

Important Caveats and Red Flags

Absolute indications for surgical referral include:

• Open fracture 3
• Incarcerated intra-articular fragment 3, 4
• Displacement ≥5mm in patients near skeletal maturity 4

Relative indications warranting orthopedic consultation:

• Ulnar nerve dysfunction at presentation 3
• Documented elbow instability on examination 2
• High-level throwing athletes or upper-extremity weight-bearing athletes 3
• Associated elbow dislocation (increases risk of stiffness and nonunion) 5

Common Pitfalls to Avoid

• Do not underestimate elbow instability based solely on fracture displacement—capsuloligamentous injuries may be present even with minimal displacement 2
• Do not assume collar-and-cuff immobilization is adequate—posterior splinting provides better pain control in the acute phase 1
• Do not delay ulnar nerve assessment—document function early as late-onset ulnar neuritis is a recognized complication 6
• Avoid prolonged immobilization beyond 4 weeks, as this increases stiffness risk without improving union rates 1