Study compares surgical and nonsurgical treatments

Whether to treat an adolescent’s medial epicondyle fracture with surgery or casting is a controversial issue, particularly for isolated, displaced fractures. Many orthopaedists are reluctant to treat young overhead athletes with casting alone because of the lack of data on this population and the risk for instability.

According to results of a retrospective study presented by J. Todd R. Lawrence, MD, PhD, at the annual meeting of the American Orthopaedic Society for Sports Medicine, casting is associated with statistically, but possibly not clinically significant, better outcomes when compared with surgical treatment. Both treatments also allowed a full return to competitive overhead sports.

Comparing treatment regimens
“Available retrospective studies have demonstrated a success rate of approximately 90 percent with both surgical and nonsurgical treatments. No studies, however, have shown equivalence or superiority of one treatment over the other,” said Dr. Lawrence. “In addition, none of the previous studies used validated outcome tools to assess outcomes and few included overhead athletes or measured their ability to return to sport.”

The study included 20 patients—13 boys and 7 girls—with an average age of 12.8 years. “Every patient com­pleted a phone survey and written questionnaires. We used the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome tool, which has recently been validated for pediatric elbow fractures,” said Dr. Lawrence.

Fourteen patients (nine boys and five girls) were treated surgically and six patients (four boys and two girls) were treated nonsurgically (Fig. 1). The surgical group included six patients who had associated dislocations.

The average fracture displacement in the surgical group was 7.6 mm (±2.7 mm), while the average fracture displacement in the casting group was 5.3 mm (±2.0 mm).

Casting associated with better outcomes
“Although both groups had good clinical outcomes,” explained Dr. Lawrence, “a statistically significant difference was found in the DASH Scores (p = 0.04). Surgical patients scored 1.3 (±1.9) versus 0.1 (±0.4) for patients treated nonsurgically. The clinical significance of this finding is still unclear because almost all patients in both groups were completely satisfied with their treatment.”

The study also examined clinical outcomes for a subgroup of patients involved in competitive sports.

“We identified 14 patients who were competitive overhead athletes in baseball and tennis and quarterbacks in football,” said Dr. Lawrence. “Eight of these patients were treated surgically and six were treated conservatively.

“All were able to return to their sport and were completely satisfied with their treatment. Nonsurgical treatment was again associated with better clinical outcomes as evidenced by the DASH scores—1.4 (±2.2) for the surgical treatment group versus 0.1 (±0.4) for the casting group,” he said.

Seven of the overhead athletes were pitchers who sustained fractures while throwing. Four were treated surgically and three received conservative treatment. All returned to baseball at the appropriate “next level” with the exception of one pitcher in each group who stopped pitch­ing for reasons not related to the injury.

“Although this is a small cohort,” Dr. Lawrence noted, “from a demographic standpoint, they were very homogenous. They had nearly identical amounts of fracture displacement.

“Once again, the trend for better outcomes was associated with nonsurgical treatment,” he said. “The clinical significance of this finding, however, is debatable, especially given the small difference that we observed and the many biases inherent in this study population.”

Next step: Prospective trials
Based on the results of this study, Dr. Lawrence stated that “the jury is still out on the proper treatment for this injury” and that “the only way to truly know if we are comparing similar populations of patients will be to conduct a prospective trial.”

“We have demonstrated that both surgical and nonsurgical treatments are associated with good clinical outcomes. More importantly, in a small cohort, we have shown that nonsurgical treatment of overhead athletes, particularly pitchers, can be safe and allow for full return to competition. This is the key contentious population that has made many surgeons wary about proceeding with a prospective trial to finally answer this important clinical question. We feel that these data fulfill the required burden of equipoise and are thus proceeding with a prospective trial to further investigate the equivalence or superiority of one treatment over the other, especially concerning the degree of rotation and displacement,” he concluded.

Additional coauthors for “Return to competitive sports following medial epicondyle fracture in adolescent athletes: A comparison of operative vs. nonoperative treatment” include Theodore J. Ganley, MD; Jonathan Macknin, MD; John M. Flynn, MD; Danielle Cameron, BA; and Hayley C. Wolfgruber, BA.

None of the authors reported any conflicts of interest related to this study.

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org