Management of Pediatric Medial Epicondyle Fractures: Results of a Survey of the Pediatric Orthopaedic Society of North America (POSNA).

Abstract

Fractures involving the medial humeral epicondyle are common but no consensus on the best treatment approach exists. Casting alone and open reduction with internal fixation (ORIF) both provide reliable healing, although there is limited evidence to support either approach. This study surveyed surgeons treatment preferences for pediatric medial epicondyle fractures (MEF) and willingness to randomize between casting and ORIF. We hypothesized that low consensus exists in the preferred treatment approach (casting vs. ORIF). An online survey was emailed in 2017 to members of the Pediatric Orthopaedic Society of North America (POSNA). Demographic information regarding orthopaedic surgeon practice experience and setting, in addition to opinions regarding MEF treatment, were collected. Seven patient cases were presented to assess the surgeon's preferred treatment approach and willingness to randomize treatment. The survey was completed by 322 POSNA members (∼25% of membership). Respondents were well-represented by POSNA with 55.7% <9, 23.8% 10 to 19, and 20.5% ≥20 years in practice. Most respondents were from an academic setting (77.4%), taught residents (83.3%), and treated primarily pediatric patients (91.6%). Years of experience significantly influenced both their treatment preferences and willingness to randomize, while practice setting only influenced the latter. Factors that influenced treatment approach included chronological/skeletal age (64.2%), known elbow dislocation (74.1%), neurovascular status (65.3%), and the amount of fragment displacement (80.4%). Displacement contributed to the treatment decision with 1.1% opting to operate at any displacement, 2.7% at >2 mm, 24.6% at >5 mm, 27.7% at >10 mm, and 43.9% choosing to analyze factors beyond displacement. Immobilization length varied between the treatments with 63.6% recommending immobilization of ≥4 weeks for casting and 81.9% recommending immobilization of ≤2 weeks for ORIF. The greatest consensus (87%) for ORIF was found in a 14-year-old with a fracture fragment displaced >10 mm, with no elbow dislocation and in the nondominant arm, neurovascularly intact. The lowest consensus (50.9% recommending ORIF) was in an 11-year-old with a fracture fragment displaced >10 mm, with no elbow dislocation and in the nondominant arm, neurovascularly intact. For these cases, 48% and 60% of surgeons were willing to randomize treatment, respectively. For the 7 cases overall, a mean of 58% (range: 48% to 63%) of respondents were willing to randomize treatment. A lack of standardization exists for the preferred treatment approach for pediatric MEF. The decision to pursue casting or ORIF appears multifactorial. Roughly half of the respondents would be willing to randomize the treatment of these injuries.