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Elbow Osteochondritis Dissecans


Elbow Osteochondritis Dissecans of the capitellum is a non-inflammatory degeneration of subchondral bone occurring in the context of repetitive trauma to the lateral compartment of the elbow.

Panner’s disease and Elbow OCD may represent two different stages of the same disorder, but they do have different characteristics:

  1. Age of onset, cause, and natural history: Although Panner’s disease affects children younger than 10 years, elbow OCD victimizes older athletes, usually between the ages of 11 and 15 years.
  2. Unlike Panner’s disease, elbow OCD is thought to be directly linked to repetitive trauma.
  3. OCD is not always a self-limited disease, and if left unaddressed, it results in profound destruction of the capitellum.
See Also: Panner’s Disease

Related Anatomy

The elbow’s osseous anatomy and the capitellum’s idiosyncratic blood supply may predispose young athletes to OCD. The elbow is a diarthrodial joint in which the distal humerus articulates with the proximal ulna and the radial head. Its unique bony configuration allows for 15 to 0 degrees° of extension to 150 degrees of flexion. Rotation of the radial head over the stationary ulna gives an arc of almost 180 degrees of forearm rotation.

The osseous and articular congruency of the humerus, ulna, and radial head accounts for the greater part of elbow stability, particularly at less than 20 degrees of extension or more than 120 degrees of elbow flexion. In young, skeletally immature athletes, the elbow possesses a greater degree of cartilaginous elasticity.

Hyperextension, facilitated by this increased range of motion, can generate increased radiocapitellar compressive loads and tension of the medial capsule and ulnar collateral ligament (UCL). Overhead throwing athletes during the throwing motion and gymnasts during weight-bearing handstands in elbow hyperextension further exaggerate these stresses. Repetitive stress on this system can precipitate OCD.

The tenuous end-artery vascular supply to the capitellum predisposes it to injury. In the young adult population, the capitellum is supplied by two end arteries coursing from posterior to anterior, which are branches of the radial recurrent and interosseous recurrent arteries . As a result of the longitudinal blood supply to the capitellar epiphyseal plate and minimal collateral circulation in the area, blood flow to the capitellum may be disrupted by repetitive microtrauma resulting in an avascular state and by a single traumatic event leading to posttraumatic subchondral bone bruises.

vascular supply to the capitellum
Capitellar blood supply. In young adults (<20 years), the radial recurrent and interosseous recurrent arteries give off branches that course from posterior to anterior and supply the capitellum (circle). This end-artery blood supply makes the capitellum susceptible to an avascular insult

Elbow OCD Causes

Elbow OCD arises from repetitive, excessive compressive forces generated by large valgus stresses on the elbow during throwing or racket swinging or by constant axial compressive loads on the elbow, such as those endured by gymnasts.

Specific risk factors predispose to the condition:

  1. In the case of baseball players, throwing sliders and breaking pitches, throwing more than 600 pitches per season,
  2. Increased age of the athlete increase the risk of developing OCD.
  3. In female gymnasts, overtraining involving excessive handstand maneuvers has been linked to OCD.
  4. There also may be a genetic predisposition to OCD.
Elbow OCD radiology
An anteroposterior radiograph shows the osteochondritis dissecans lesion (circle) more clearly with elbow fl exed to 45 degrees

Elbow OCD Symptoms

Patients with elbow OCD initially complain of pain and stiffness in the elbow that is relieved by rest. The onset is usually insidious, and a history of specific trauma is often absent. If left unaddressed, the symptoms may progress to locking or catching due to intraarticular loose bodies or an inflamed plica.

Throwing athletes may present with painful posterolateral clicking or catching caused by a radiocapitellar plica. These symptoms can overlap with those from the elbow OCD lesion, and the plica itself may be responsible for chondral wear in the radiocapitellar compartment.

Physical Examination

Because throwing athletes may have injured medial and lateral and posterior elbow structures, a full elbow examination is essential. UCL integrity is tested by performing a valgus stress test at 30 degrees, the milking maneuver, and the moving valgus stress test.

Posteromedial impingement is evaluated by performing a bounce test. A positive test result elicits pain posteromedially when the elbow undergoes forced hyperextension.

Loss of range of motion with a 15- to 20-degree flexion contracture is common. Loss of extension is more common than loss of flexion.

An effusion is often apparent and can be palpated by flexing the elbow and feeling the lateral portal area, triangulated by the radial head, olecranon, and lateral epicondyle.

The provocative maneuver for the radiocapitellar joint is the active radiocapitellar compression test. A positive test result elicits pain in the lateral compartment of the elbow when the patient pronates and supinates the forearm with the arm in extension.

In patients with an associated symptomatic radiocapitellar plica, snapping typically occurs at greater than 90 degrees of elbow flexion with the forearm in pronation.

See Also: 
radiocapitellar compression test
In the radiocapitellar compression test, pain in the lateral elbow is elicited when the extended arm is pronated and supinated

Radiology

Anteroposterior radiographs in full extension, anteroposterior radiographs in 45 degrees of flexion, and lateral views of the elbow should be obtained. Radiographic findings may be negative early in the disease process. As the condition progresses:

  1. flattening and sclerosis of the capitellum, typically on its anterolateral aspect, will become apparent.
  2. Irregular areas of lucency and intra-articular loose bodies also appear.

The capitellar lesions of OCD and medial-sided epicondylar fragmentation are best seen on an anteroposterior radiograph at 45 degrees of elbow flexion.

MRI should be used to assess suspected Elbow OCD. It can detect bone edema early in the disease process. An MR arthrogram can further delineate the extent of the injury. Contrast can show separation of a detached or partially detached piece from subchondral bone. This is important in determining whether to proceed with operative or nonoperative management.

elbow OCD MR arthrogram
The MR arthrogram shows contrast surrounding an unstable elbow osteochondritis dissecans fragment (arrow).

Elbow Osteochondritis Dissecans Treatment

Treatment of Elbow OCD lesions is based primarily on the status and stability of the overlying cartilage. The size and location of the lesion and the patency of the capitellar growth plate also influence decision making.

Elbow Osteochondritis Dissecans Treatment

Stage I (Stable):

MRI Findings:

  • Normal radiograph
  • T1 abnormal – T2 normal

Arthroscopic Findings:

  • Intact articular cartilage
  • Subchondral bone edema but structurally sound

Treatment:

  • Hinged elbow brace for 3-6 wk
  • Physical therapy
  • NSAIDs
  • Follow-up radiograph and/or MRI at 3-6 mo
stage 1 elbow osteochondritis dissecans lesion on mri
Progress of a stage 1 elbow osteochondritis dissecans lesion is evaluated on magnetic resonance imaging (MRI). A stable, intact, nondisplaced fragment (circles) has abnormal signal intensity on coronal slices in T1-weighted (A) and T2-weighted (B) MRI sequences. After 6 months of conservative management, the T1-weighted (C) and T2-weighted (D) MRI sequences show reconstitution of subchondral bone in the area of the lesion. The patient was symptom free at the 6-month follow-up assessment.

Stage II (Unstable):

MRI Findings:

  • Abnormal radiograph
  • T1, T2 abnormal
  • Contrast shows margin around lesion

Arthroscopic Findings:

  • Partially detached fragment
  • Cartilage fracture
  • Subchondral bone collapse
  • Lateral buttress involved with a poorer prognosis.

Treatment:

  • Acute: consider fragment fixation, buthigher success treating as chronic condition
  • Chronic:
    • <6-7 mm lateral buttress involved, radial head does not engage: fragment removal, microfracture drilling
    • >6-7 mm lateral buttress involved, head engages: removal, osteochondral autograft, synthetic graft.
stage 2 osteochondritis dissecans lesion
A stage 2 elbow osteochondritis dissecans lesion is assessed by magnetic resonance imaging (MRI). T1-weighted (A) and T2-weighted (B) MRI sequences show a margin around the fragment (circles), denoting its instability.
Elbow Osteochondritis Dissecans arthroscopy
A stage 2 elbow osteochondritis dissecans lesion is assessed arthroscopically. A, The arrow points to the osteochondral fragment located at its donor site. B, The arrow points to the space between the osteochondral fragment and bone, denoting fractured cartilage and instability.

Stage III (Unstable):

MRI Findings:

  • Loose bodies

Arthroscopic Findings:

  • Completely detached Loose bodies

Treatment:

  • Loose body removal
  • Treat as stage 2 lesion.
stage 3 osteochondritis dissecans lesion
A stage 3 elbow osteochondritis dissecans lesion is assessed by magnetic resonance imaging (MRI) and arthroscopy. T1-weighted, coronal MRI (A) and T1-weighted, sagittal MRI (B) show an unroofed lesion. C, Arthroscopy shows the lesion (oval) with no overlying cartilage. Small arrows demarcate edge of lesion. D, The loose body osteochondral fragment (arrow) is found in the joint.

Associated radial head OCD

Associated radial head OCD is treated as following:

  1. < 30% radial head involvement: treat as stage 2 lesion
  2. > 30% radial head involvement: no osteochondral grafting; microfracture drilling okay.
elbow ocd arthroscopy
The elbow osteochondritis dissecans lesion with an intact lateral column. A, The lesion (oval) is adjacent to a significant portion of the intact lateral column (arrow). B, The lateral column (arrow) supports the radial head and does not permit engagement with the defect

References

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  2. Voloshin I, Schena A . Elbow injuries . In: Schepsis AA, Busconi BD , eds. Sports Medicine . Philadelphia, PA : Lippincott Williams & Wilkins; 2006 .
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  4. Morrey BF, Tanaka S, An KN . Valgus stability of the elbow. A definition of primary and secondary constraints . Clin Orthop Relat Res. 1991 ( 265 ): 187 – 195 .
  5. Kocher MS, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete . Sports Med. 2000 ; 30 : 117 – 135 .
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  9. Lyman S, Fleisig GS, Waterbor JW , et al . Longitudinal study of elbow and shoulder pain in youth baseball pitchers. Med Sci Sports Exerc. 2001 ; 33 : 1803 – 1810 .
  10. Caine D, Howe W, Ross W, Bergman G . Does repetitive physical loading inhibit radial growth in female gymnasts? Clin J Sport Med. 1997 ; 7 : 302 – 308 .
  11. Caine DJ, Nassar L . Gymnastics injuries . Med Sport Sci. 2005 ; 48 : 18 – 58.
  12. Griffith JF, Roebuck DJ, Cheng JC , et al . Acute elbow trauma in children: spectrum of injury revealed by MR imaging not apparent on radiographs. AJR Am J Roentgenol. 2001 ; 176 : 53 – 60 .
  13. Peiss J, Adam G, Casser R , et al . Gadopentetate-dimeglumine-enhanced MR imaging of osteonecrosis and osteochondritis dissecans of the elbow: initial experience . Skeletal Radiol. 1995 ; 24 : 17 – 20 .
  14. Baumgarten TE, Andrews JR, Satterwhite TE . The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum . Am J Sports Med. 1998 ; 26 : 520 – 523 .
  15. DiFelice GS, Meunier M, Paletta GJ . Elbow injury in the adolescent athlete. In: Altchek AJ , ed. The Athlete’s Elbow. Philadelphia, PA: Lippincott Williams & Wilkins ; 2001 : 231 – 248 .
  16. Mihara K, Tsutsui H, Nishinaka N, Yamaguchi K . Nonoperative treatment for osteochondritis dissecans of the capitellum . Am J Sports Med. 2009 ; 37 : 298 – 304 .
  17. Takahara M, Mura N, Sasaki J , et al . Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum . J Bone Joint Surg Am. 2007 ; 89 : 1205 – 1214 .
  18. Takahara M, Mura N, Sasaki J , et al . Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. Surgical technique. J Bone Joint Surg Am. 2008 ;90(suppl 2, pt 1): 47 – 62 .
  19. Petrie R, Bradley JP . Osteochondritis dissecans of the humeral capitellum. In: De Lee J, Drez D, Miller M , eds. Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, PA : WB Saunders ; 2003 .
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Last Reviewed
November 27, 2022
Contributed by
OrthoFixar

Orthofixar does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice.

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