Article Text

Download PDFPDF
Systematic review
Optimal management of physeal elbow injuries in the skeletally immature athlete remains undefined: a systematic review
  1. Brittany E Haws1,2,
  2. Austin V Stone2,
  3. Andrew O Usoro3,
  4. Alejandro Marquez-Lara1,
  5. Sandeep Mannava4,
  6. Michael T Freehill5
  1. 1 Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, North Carolina, USA
  2. 2 Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
  3. 3 Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
  4. 4 Department of Orthopaedics and Rehabilitation, Division of Sports Medicine, University of Rochester, Rochester, New York, USA
  5. 5 Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Michael T Freehill, University of Michigan, Department of Orthopaedic Surgery, Ann Arbor, MI, 48106-0391, USA; freehill{at}


Importance Physeal elbow injury remains common for the youth athlete. In this patient population, the most effective treatment strategy for these injuries is not established.

Objective This systematic review aimed to synthesise current literature regarding treatment and outcomes of physeal elbow injuries in the skeletally immature athlete.

Evidence review A systematic literature review was completed using two databases (PubMed and ScienceDirect). Search terms included ‘paediatric elbow injury’, ‘adolescent elbow injury’, ‘elbow physeal injury’, ‘avulsion fracture medial epicondyle’ and ‘little league elbow’. Inclusion criteria were: English language, Level of Evidence I–IV, physeal elbow injury as a direct consequence of athletic activity, involvement of a distinct treatment modality and/or outcome, publication after 1989 and skeletal immaturity demonstrated through radiographic measurements.

Findings Twelve studies consisting of treatment of avulsion fractures of the medial epicondyle, medial epicondyle fragmentation, olecranon stress fractures and olecranon apophysitis met criteria and were included in this study. The most common injury was avulsion fracture of the medial epicondyle. Of these patients, 68.5% underwent operative fixation with average return to play at 3.3 months and 31.5% underwent non-operative treatment with an average return to play of 8.4 months. For medial epicondylar fragmentation, 90.2% of patients were treated non-operatively with average return to play at 3.8 months. Operative intervention was performed on 85.7% of patients with olecranon epiphysial stress fractures and average return to play was at 7 months. Operative intervention was performed on 87.5% of patients with persistence of the olecranon physis with average return to play of 4 months. All cases of olecranon apophysitis were treated non-operatively and return to play was not documented.

Conclusions and relevance This systematic review demonstrates the heterogeneity of the treatment options for physeal injury in the adolescent athlete. This analysis supports that operative management may expedite return to play for avulsion fracture of the medial epicondyle, though medial epicondylar stress fractures can be successfully managed non-operatively. Limited data suggest surgical intervention of olecranon epiphysial stress fractures and persistence of the olecranon physis may allow athletes faster return to play.

Level of evidence IV.

  • elbow
  • sport specific injuries
  • outcome studies
  • bone
View Full Text

Statistics from


  • Contributors AM-L, SM and MTF contributed to conception and design of the work. BEH, AOU and SM performed data acquisition, analysis and drafted the manuscript. AVS, AM-L, SM and MTF provided significant revisions to the manuscript. All authors provided final approval and agreed on accountability for the work.

  • Funding No funds were received in support of this work. No benefits in any form have been or will be received from any commercial party related directly or indirectly to the subject of this manuscript.

  • Competing interests MTF is a consultant for Smith & Nephew and Depuy Mitek, provides research support to RTI Surgical and Smith & Nephew and is a committee member of AAOS, AOSSM, ISAKOS and AANA. SM receives research support from ABMS-ABOS and is a committee member of AANA.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Data sharing statement The corresponding author will share unpublished data on request, subject to various conditions.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.