Timing Matters: Challenges in Delayed Surgical Management of Pediatric Humeral Medial Epicondyle Fractures

Background: Humeral medial epicondyle fractures comprise 12% of pediatric elbow injuries. Delay in surgical intervention may be more involved than acute surgery due to soft tissue shortening, fragment-induced joint surface damage, elbow stiffness, and ulnar nerve displacement/scarring. There are limited prior case reports on delayed surgical management. The purpose of this study is to provide a descriptive analysis of a series of medial epicondyle fracture patients treated with delayed surgical management. Methods: Delayed surgical management was defined as any operative repair of the medial epicondyle fracture performed >3 weeks from the injury date. A retrospective review of patient records from 2012 to 2022 was performed from a single pediatric institution based on current procedural terminology (CPT), International Classification of Diseases (ICD) 10, and ICD 9 codes. Inclusion criteria consisted of: (1) patients younger than 18 years with a diagnosis of medial epicondyle fracture; (2) delayed surgical management of the medial epicondyle fracture performed at our institution; and (3) availability of preoperative and postoperative radiographs. Data collected included demographics, injury characteristics, symptoms, time and reason for delayed surgery, procedural details, and postoperative outcomes. Results: Thirteen patients (3.7% of total operative medial epicondyle cases) underwent delayed surgical management by 1 of 4 pediatric orthopaedic surgeons. Reasons for delay included: failed initial nonoperative management (46%), delay in imaging (23%), delay in first outpatient visit (23%), and initial missed diagnosis (8%). Fifty-four percent of patients (7/13) were surgically treated between 3 weeks and 3 months from injury. All underwent either successful open reduction internal fixation (ORIF) or partial fragment excision with direct repair of the medial ulnar collateral ligament (UCL) and/or flexor pronator mass (FPM). Twenty-three percent (3/13) were treated between 3 months and 1 year from injury, and 23% (3/13) were treated over 1 year from injury. Significant medial soft tissue contracture played a key role in the management of these cases, resulting in soft tissue lengthening, nonanatomic reduction, or UCL reconstruction. Overall, 46% (6/13) were also treated with ulnar nerve decompression or transposition. Conclusions: ORIF or direct repair of the UCL and FPM is feasible for delayed surgical management of pediatric medial epicondyle fractures within 3 months of injury. For delays > 3 months, the degree of fragment displacement and patient age should be considered for optimal treatment and timing, and surgeons should be prepared to perform alternative treatments, including soft tissue releases and UCL reconstruction. Level of Evidence: Level IV.