Study finds benefit in nonoperative treatment for medial epicondyle fractures in adolescent athletes

ORLANDO — Investigators from Children's Hospital in Philadelphia have reported that although operative and nonoperative treatments for medial epicondyle fractures in young athletes result in good results, validated outcomes measures have shown a trend toward better clinical outcomes with nonoperative treatment.

"However the clinical significance of this finding is debatable, especially given the magnitude of the differences that we observed and the many biases inherent to this particular study population," noted J. Todd Lawrence, MD.

Lawrence's comments came during the 2008 American Orthopaedic Society for Sports Medicine Annual Meeting, here.

The investigators looked at 20 patients at an average age of 12.8 years, who were available for a mean 3.6 years follow-up. Of these, 14 were treated surgically and six were treated nonsurgically. The demographics were similar between the groups, however, six patients in the operative group had associated dislocations of the elbow and there was a trend toward a greater amount of fracture displacements in the group treated operatively, Lawrence said.

The athletes were assessed subjectively via phone interviews and questionnaires and clinically via DASH scores.

All of the patients played competitive sports prior to injury and were able to progress to the next level after treatment. DASH scores demonstrated statistically superior outcomes for patients treated nonoperatively compared with patients treated operatively, 0.12 ± 0.33 vs. 1.33 ± 1.81, according to the study abstract.

"There was a statistically significant difference in the DASH scores with nonoperative treatment being associated with better clinical outcomes, however, the clinical significance of this finding is still unclear given that all patients in both groups noted that they were completely satisfied with their treatment," he said.

A subset of 14 competitive overhead athletes were factored out of the overall population, eight were treated operatively and six nonoperative. Of these, "all returned to their sport and were completely satisfied with their treatment," Lawrence said. "And again, nonoperative treatment did show a trend toward better outcomes with the DASH."

He said, "Most importantly we have demonstrated that nonoperative treatment in the overhead athletes, particularly pitchers, can be safe and offers a full return to competition."

However, he noted that significant treatment-bias that inherently influences this type of analysis validates the need for prospective trials to clarify the optimal treatment for this injury.

In discussing the study, James R. Andrews, MD, of Birmingham, Ala., said that nonoperative treatment of these young athletes worries him. "When you have displacement, kids who are treated nonoperatively may get a prolonged period of immobilization. And what we see out in the fields is that this leads to a stiff elbow or a lot of nonunions that are too late to fix. Some you can never get bone-to-bone.

"We have been extremely aggressive ... when we see them displaced, we fix them and move them early with little or no immobilization. I think there is still work to be done to decide what to do with this problem."

For more information:
Lawrence JT, Macknin JB, Flynn JM, et al. Return to competitive sports following medial epicondyle fracture in adolescent athletes: A comparison of operative vs. nonoperative treatment. Presented at the American Orthopaedic Sports Medicine Society 2008 Annual Meeting. July 10-13, 2008. Orlando.