The medial epicondyle serves as the proximal attachment of the medial ulnar collateral ligament and the origin of the flexor pronator musculature and as such it is responsible for resisting the main static and dynamic restraints to valgus force at the elbow. Fractures through the physis in the developing elbow are common and treatment remains controversial. Biomechanical modeling predicts that anterior should be the direction of greatest displacement. Anatomic considerations predict that anterior displacement should have the greatest effect on elbow stability and range of motion making the ulnar collateral ligament too loose in flexion and too tight in extension and potentially leading to valgus laxity in flexion and a block to full extension. In the elite overhead athlete, where elbow stability is critical both for sports performance and the long-term health of the elbow, assessment of anterior displacement is thus theoretically an important consideration. Standard radiographic views cannot adequately assess anterior displacement. Specialized radiographs and 3-dimensional modalities such as computerized tomography and magnetic resonance imaging can adequately assess anterior displacement and in the overhead athlete can sometimes aid in the decision-making process. Here, we present a review of the current literature and the rationale for a treatment algorithm for medial epicondyle fractures in the skeletally immature overhead athlete.