Surgical versus non-surgical management of pediatric medial epicondyle fractures: a systematic review and meta-analysis

Background The optimal management of medial epicondyle fractures remains controversial, particularly in displaced fracture without incarceration. Traditionally, non-surgical treatment remains the treatment of choice for the management of medial epicondyle fracture; however recent evidence suggesting favorable outcomes with surgical fixation has increased interest in operative management. This systematic review and meta-analysis aimed to compare surgical versus non-surgical treatment for the management of medial epicondyle fracture in pediatric population to determine the optimal management therapy. Methods A systematic search of PubMed, Cochrane Library, and Google Scholar and Clinical trial govt. was conducted from inception to April 2026 according to PRISMA guidelines (PROSPERO: CRD420261393871 ) . Randomized controlled trials and observational studies were included. Statistical analyses were performed using a random-effects model in RevMan 5.4. Risk of bias was evaluated using the Cochrane RoB 2 tool and Newcastle–Ottawa Scale, while certainty of evidence was assessed using GRADE. Results Six comparative studies involving 564 pediatric patients were included, comprising two randomized controlled trials and four cohort studies. Surgical fixation significantly reduced the risk of non-union (RR = 0.09, 95% CI: 0.02–0.39; p = 0.001) and worse cosmetic VAS scores (MD = − 8.56, 95% CI: −12.66 to − 4.46; p < 0.0001), favoring non-surgical management. However, surgery was associated with a significantly greater likelihood of requiring additional surgery (RR = 13.37, 95% CI: 5.20–34.35; p < 0.00001). No significant differences were observed between groups for DASH scores, elbow flexion or extension deficits, PedsQL scores, or valgus instability tests. Conclusion Surgical treatment reduces nonunion but is associated with worse cosmetic outcomes in pediatric medial epicondyle fracture. However, its effect on functional outcomes remains uncertain compared with non-surgical treatment. Treatment decisions should therefore be individualized based on clinical and patient-specific factors.