Medial epicondyle fracture delayed union 14 year old

[dlo]

My 14 year old son sustained an acute medial epicondyle fracture pitching July 2016.  Displacement was 3-4 mm and was treated with rest/immobilization for 3 weeks followed by range of motion and cross training.  Follow up x-rays at 3.5 months show no bony union and no callous.  Symptoms are improved: mild stiffness at times, full range of motion, and occasional inconsistent pain with weights or stress, no swelling.  He has not thrown a ball.  Boy estimates he is at 70% to baseline at 3.5 months.

The question is should we continue this non-operative approach and hope that additional healing occurs and he can throw again with a fibrous union at the fracture site?  Or, should we be more aggressive with screw fixation of the fracture?  Do these options or risks change as time goes by? Do we burn a bridge when choosing one option over the other? Risks?


Thanks much,
DLO

[Marcus Rothermich, MD]

This is an interesting topic with, unfortunately, more than one opinion on the clear path forward. Generally, non-operative treatment should lead to some callous formation within the first few months. The difficulty is that he is seemingly doing reasonably well with little pain and full ROM. However, this may mask how he will feel when he gets back to full activity if he does not have bony union at the fracture site. You are completely in the right mindset at this time of his recovery, and if repeat radiographs continue to show no callous formation, we would generally begin the discussion about screw fixation. The only downside of surgery is that it starts the clock over on his recovery, but typically results in full activity and bony union with no problems. Continuing down the road of non-operative treatment avoids all minor risks of surgery (infection, etc) but could lead to an unsatisfactory outcome if his radiographs don't change soon.

Hope this helps!

[dlo]

Thank you for your response.
If fracture does indeed go on to non-union (I read this can happen 50% of time), do you have a percentage likelihood he can play field position vs pitch with a fibrous union? Do the percentages change or stack in our favor with surgery at time 1 year, 2year, etc. One AJSM study suggests similar retrospective outcomes 2 years post injury of surgery vs non-surgery treatments (doesn't discuss non-unions). We are open to surgery or non-operative care; we want to make the best long term decision as we approach HS and college.

Any issues with UCL long term and it's relationship to the above.

Thanks again.
DLO

[Glenn Fleisig, Ph.D.]

dlo,

I am not a surgeon like Dr. Rothermich, but my understanding is that surgical treatment should always be the last option. There are certainly cases where it is time for that last option (because the injury is substantial), but the benefit of non-surgical option (when feasible) for most orthopaedic injuries is that the body accepts the natural repair and long-term risks like arthritis are not inflated.

Dr. Rothermich and I have provided some insights, in general, but we cannot make specific opinions about your son's situation. This is between you and your son's physician. If you want to, you can post here or click on my name and send me a private message about whom your doctor is and what city you are near. I can give you opinions about particular physicians in your area.

Other questions you are most likely asking yourself are why did this injury happen in the first place, and what can we do to minimize the risk of injury in the future. Although your son was diagnosed with an "acute" pitching, the overwhelming majority of pitching injuries develop over time. An acute event is often "the last straw". That is, the fracture in your son's elbow was building up game-after-game, pitch-after-pitch, until finally it broke. So you need to ask whether your son was pitching too much and/or had symptoms such as fatigue and pain that were ignored until they became a problem. Once the injury is treated (surgically or non-surgically), I recommend you follow the guidelines of www.pitchsmart.org.

Good luck. You are obviously a parent who cares about her son.

[dlo]

Thank you for your reply.
When more than one option exists, it certainly makes the decision a little less black/white.
I appreciate your opinion very much.
DLO