Seventy-two children with displaced medial humeral epicondyle fractures were randomized to receive open surgical reduction and internal fixation followed by casting (n=37) or casting alone without reduction (n=35). The primary outcome of interest was the QuickDASH score at 12 months. Secondary outcomes included elbow range of motion, grip strength, return to sports, cosmetic appearance, and rates of fracture union. Outcomes were assessed at 1, 3, 6, and 12 months. Overall, the results of the study revealed that casting was noninferior to surgery in terms of functional outcome at 12 months, despite a higher rate of radiographic nonunion. Cosmetic appearance favored casting, and all participants returned to their preinjury activities. These findings suggest casting alone is an effective treatment option for displaced pediatric medial epicondyle fractures at 1-year follow-up.