A fracture of the medial epicondyle of the elbow can present as a small avulsion or as a much more unstable injury, often associated with dislocation. The amount of displacement is important, but it alone does not describe the problem.
Age, dominant limb, sports activity, elbow stability, ulnar nerve integrity, and the presence of an incarcerated fragment can modify the indication. The Royal Children's Hospital guidelines, for example, consider precisely these elements when radiographic displacement is intermediate. [1,2]
Why the medial epicondyle is not just "a small fragment"
The medial epicondyle is the bony prominence on the inner side of the elbow. In children and adolescents, it corresponds to an apophysis, which is an area still undergoing skeletal maturation.
It is an important anchoring point for the forearm's flexor-pronator complex and for the medial ligamentous compartment of the elbow. In practical terms, this region contributes to the stability of the inner side of the elbow, especially when the joint is subjected to valgus stress.
Many fractures heal well with conservative treatment. Associated dislocation, instability, neurological symptoms, or high sports demands, however, require more careful evaluation.
The first point to clarify: was the elbow dislocated?
Elbow dislocation changes the clinical significance of the fracture.
When the elbow dislocates, the medial epicondyle can detach due to traction and, after reduction, may remain incarcerated within the joint. This situation must be recognized immediately: the elbow may appear "back in place," but the fragment can still be interposed between the articular surfaces.
For this reason, after reduction of an elbow dislocation, follow-up X-rays are not only for confirming that the joint is reduced. They also serve to verify that the medial epicondyle has not remained trapped inside the elbow. The RCH guidelines clearly state that, in case of doubt of intra-articular incarceration, urgent open reduction with internal fixation is necessary [2].
If the fragment remains incarcerated in the joint after dislocation reduction, the surgical indication is strong because a mechanical obstruction exists.
The ulnar nerve must always be evaluated
The ulnar nerve runs posteriorly to the medial epicondyle. It is the nerve responsible for the classic "shock" when you hit your elbow.
After a medial epicondyle fracture, tingling in the fourth and fifth fingers, altered sensation, electric pain, reduced strength, or difficulty with fine hand movements should therefore be sought.
Ulnar nerve involvement is an important consideration: it is among the relative indications for open reduction and internal fixation, especially if the neurological picture is clear or progressive [2].
Millimeters matter, but they don't decide alone
The measurement of displacement remains important. A non-displaced fracture, a fracture displaced by 7 mm, and one displaced by 18 mm are not the same thing.
The problem is that measurement is not always reliable. Standard X-rays can underestimate the actual displacement of the medial epicondyle, especially when the fragment moves in an anterior or antero-inferior direction. Souder and colleagues have shown that standard projections can underestimate displacement and that an axial projection of the distal elbow can estimate it more accurately and reproducibly [3].
When the decision depends on a few millimeters, the quality of the measurement matters. Even an accurate measurement must still be interpreted in context: the same displacement can have different meanings in a small, non-athletic child compared to an adolescent who practices gymnastics or throwing sports with their dominant limb.
What recent randomized trials change
In the last two years, much higher-level data have finally emerged compared to older retrospective series.
In the Finnish trial published in JAMA Network Open in 2025, 72 children aged 7 to 16 with displaced fractures over 2 mm, but without articular incarceration or ulnar nerve deficit, were randomized to either fixation or cast without reduction. At 12 months, the functional outcome was substantially comparable: conservative treatment was found to be non-inferior to surgery according to the QuickDASH. Return to sport also occurred with similar timings. However, there is one piece of data that, as an orthopedic surgeon, I do not consider secondary: radiographic non-union was present in 24 out of 35 children treated in a cast, compared to 1 out of 37 who underwent surgery. At one year, this did not translate into worse clinical outcomes, but we do not yet know how much it matters in some very active patients, subjected over time to repeated valgus stress [6].
The SCIENCE trial, published in The Lancet in 2026, is even larger: 335 children randomized across 59 hospitals in the UK, Australia, and New Zealand. Here too, fixation did not demonstrate a clinically significant functional advantage at 12 months compared to non-surgical treatment. The operated group also had more additional procedures, partly due to complications and partly for hardware removal [7].
These trials make it difficult to argue that radiographic displacement alone demonstrates a benefit of surgery in all children.
Personally, however, I do not read them as a reason to automatically shift all displaced fractures towards conservative treatment. The trials tell us that, in the average eligible population and at one year, systematically operating does not improve function. They say much less about more selected subgroups: an adolescent nearing skeletal maturity, dominant limb, sports with high valgus demands, clinical instability, complex dislocation, or a very displaced fragment where I want to achieve anatomical union and reliable medial stability in the long term.
In these cases, I continue to have a relatively low surgical threshold. This is a more interventional stance than the general conclusion of the trials, but it must be stated for what it is: a clinical choice based on the individual patient's profile, not proof that surgery is superior in everyone.
When cast treatment may be reasonable
Conservative treatment is a reasonable choice when the elbow is stable, there are no signs of intra-articular incarceration, there are no ulnar nerve symptoms, and the child's functional profile does not require particularly high medial stability. After recent trials, even significant radiographic displacement can be included in the conservative discussion, provided the case is suitable and follow-up is reliable [6,7].
In these cases, immobilization can yield good results. The "perfect X-ray" should not be pursued if it does not change the expected functional outcome.
However, one point must be clarified: radiographic non-union of the medial epicondyle can be observed after conservative treatment and is not always symptomatic. This does not mean ignoring it, but interpreting it in the clinical context: pain, instability, functional limitation, and return to sport matter more than the image alone.
When surgery should be seriously considered instead
There are situations where surgery enters the discussion much more decisively.
The first is incarceration of the fragment within the joint after dislocation: in this case, the indication is strong.
The second is ulnar nerve involvement.
The third is significant displacement, especially over 10-15 mm, even though the threshold is not universally accepted.
The fourth concerns the functional profile: adolescent, dominant limb, throwing sports, gymnastics, or activities with significant valgus stresses. The RCH guidelines specifically include the dominant arm in throwing athletes or gymnasts among the relative indications for surgery [2].
Even in athletes, the indication remains individual.
The athlete's dilemma: beware of automatic decisions
In child athletes, the decision is often more delicate.
On the one hand, surgery can better restore anatomy and reduce the risk of medial instability in selected patients. On the other hand, not all displaced fractures in an athlete automatically lead to a poor outcome if treated conservatively.
Recent randomized trials have greatly strengthened the conservative position regarding average outcomes at 12 months [6,7]. At the same time, the Finnish trial showed an enormous difference in radiographic union and a signal, though not statistically definitive, towards greater laxity on valgus stress testing in patients treated in a cast [6].
For me, this is precisely where the controversy remains open. If the goal is average function at one year, the data do not demonstrate an advantage of fixation. However, if the patient is an adolescent who will subject that elbow to high valgus demands for years, the question of stability and anatomical union remains legitimate. Currently, we do not have strong enough subgroup data to turn this consideration into a universal rule.
In sports with high valgus stresses, the level of activity, dominant limb, stability, and type of fracture matter; the mere fact of playing sports does not constitute a surgical indication.
What is truly evaluated
In a medial epicondyle fracture, one starts with the X-ray, but should not stop at the report.
It is evaluated whether the trauma was isolated or if there was an elbow dislocation. It is checked that the fragment is visible in the expected location and not incarcerated in the joint. Ulnar nerve function is documented. Age, skeletal maturity, dominant limb, sport played, and activity level are considered.
The X-ray is then read carefully: standard projections, image quality, and the actual possibility of measuring displacement. In doubtful cases, especially if the therapeutic decision depends on a few millimeters, it may make sense to resort to dedicated projections or further investigations.
Elbow stability, when assessable, completes the picture. It is not always possible to test it well in the acute phase due to pain and swelling, but clinical suspicion must be integrated with the traumatic mechanism and imaging.
The practical message
A medial epicondyle fracture should neither be dramatized nor trivialized.
Many children can be treated with a cast and recover well. In other cases, however, surgery is not an excess, but a reasoned choice: incarcerated fragment, complex dislocation, ulnar nerve involvement, marked displacement, instability, or high sports demands.
The problem is not having a universal millimeter threshold for everyone.
The problem is understanding which elbow you are dealing with.
Bibliography
[1] Kamath AF, Baldwin K, Horneff J, Hosalkar HS. Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review. Journal of Children’s Orthopaedics. 2009;3(5):345-357. PMID: 19685254. DOI: 10.1007/s11832-009-0192-7.
[2] Royal Children’s Hospital Melbourne. Clinical Practice Guidelines: Medial epicondyle fracture of the humerus – Emergency Department. The guidelines provide practical indications on incarceration, displacement, age, dominance, sport, and ulnar nerve.
[3] Souder CD, Farnsworth CL, McNeil NP, Bomar JD, Edmonds EW. The Distal Humerus Axial View: Assessment of Displacement in Medial Epicondyle Fractures. Journal of Pediatric Orthopaedics. 2015;35(5):449-454. PMID: 25171678. DOI: 10.1097/BPO.0000000000000306.
[4] Knapik DM, Fausett CL, Gilmore A, Liu RW. Outcomes of Nonoperative Pediatric Medial Humeral Epicondyle Fractures With and Without Associated Elbow Dislocation. Journal of Pediatric Orthopaedics. 2017;37(4):e224-e228. PMID: 27741036. DOI: 10.1097/BPO.0000000000000890.
[5] Axibal DP, Carry P, Skelton A, Mayer SW. No Difference in Return to Sport and Other Outcomes Between Operative and Nonoperative Treatment of Medial Epicondyle Fractures in Pediatric Upper-Extremity Athletes. Clinical Journal of Sport Medicine. 2020;30(6):e214-e218. PMID: 30277893. DOI: 10.1097/JSM.0000000000000666.
[6] Grahn P, Helenius I, Hämäläinen T, et al. Casting vs Surgical Treatment of Children With Medial Epicondyle Fractures: A Randomized Clinical Trial. JAMA Network Open. 2025;8(5):e258479. doi:10.1001/jamanetworkopen.2025.8479. PMID: 40327343.
[7] Perry DC, Achten J, Zimmermann A, et al; SCIENCE Study Collaborators. Surgical fixation versus non-surgical care for children with a displaced medial epicondyle fracture of the elbow (the SCIENCE study): a multicentre, randomised controlled, superiority trial and economic evaluation. Lancet. 2026;407(10528):577-586. doi:10.1016/S0140-6736(25)02098-7. PMID: 41576983.
Disclaimer: content for general informational purposes only. It does not replace medical evaluation.
