Casting vs Surgical Treatment of Children With Medial Epicondyle Fractures: A Randomized Clinical Trial.
Summary
In a multicenter noninferiority RCT (n=72), long-arm casting was noninferior to open reduction and internal fixation for displaced pediatric medial epicondyle fractures at 12 months by QDASH. Cosmetic ratings favored casting, while radiographic nonunion was far more common with casting but without functional detriment at 1 year.
Key Findings
- Casting was noninferior to surgery for 12-month QDASH (mean difference −0.98; 95% CI −2.95 to 0.98).
- Cosmetic visual analog scale scores favored casting (between-group difference −8.9; 95% CI −16.6 to −1.2).
- Radiographic nonunion was 68.6% with casting versus 2.7% with surgery; no crossovers occurred.
Clinical Implications
Nonoperative casting can be offered confidently for displaced medial epicondyle fractures with counseling on high nonunion rates and the lack of short-term functional harm. Surgical indications should be individualized, and long-term outcomes monitored.
Why It Matters
High-quality randomized evidence challenges increased surgical use and supports casting as an effective first-line option. Cosmetic outcomes and functional parity may influence shared decision-making.
Limitations
- Sample size modest (n=72) and 12-month horizon; longer-term functional impact of nonunion unknown
- Cosmetic and function outcomes may be influenced by lack of blinding
Future Directions
Evaluate long-term functional, cosmetic, and return-to-sport outcomes, and define subgroups that benefit from surgery versus casting.
Study Information
- Study Type
- RCT
- Research Domain
- Treatment
- Evidence Level
- I - Randomized controlled trial with prospective registration and predefined primary endpoint
- Study Design
- OTHER