Osteochondritis Dissecans, Elbow (Pediatric)

Synonyms
Osteochondritis dissecans of elbow, OCD

INTRODUCTION

Definition

A localized fragmentation with subsequent separation of articular cartilage and subchondral bone of the capitellum. 

Epidemiology

  • Capitellar OCD typically occurs in patients 10-16 years of age (after 10 years of age).
    • The condition is commonly found in young (10 year old) baseball pitchers. This is due to a valgus position that the elbow assumes which loads the capitellum during the acceleration phase.
    • Osteonecrosis of the capitellum (Panner disease) typically occurs in the first decade of life.
  • More common in boys than girls.
  • Typically located in capitellum of dominant arm.
  • It frequently causes permanent disability.

Patogenesis

  • OCD result from repetitive overuse or overload compression type injuries, resulting in repetitive microtrauma and insult to the blood supply of the immature capitellum.
    • Risk factors include repetitive overhead and upper extremity weight bearing activities that are seen in gymnasts and baseball pitchers (throwing sports).
  • It may progress to loose body formation, and sometimes to posttraumatic arthritis.
  • Laxity of the MCL may accentuate the loading on the capitellum.

Classification

Guhl classification
  • Type 1: Intact cartilage. Bony stability may or may not be present.
  • Type 2: Cartilage fracture with bony collapse or displacement.
  • Type 3: Loose bodies present in joint.

CLINICAL FEATURES

Symptoms

The patient will have poorly localized lateral elbow pain, sometimes with catching and locking.
  • Elbow pain: Insidious, activity-related onset of lateral elbow pain in dominant arm.
  • Mechanical symptoms:
    • Reduced or loss of extension is an early sign.
    • Catching, locking and/or grinding are late signs if loose bodies present.

Signs

Inspection:
  • Swelling and flexion contractures are common.
  • Usually mild effusion of elbow joint.
Palpation: Lateral elbow tenderness. 
Movement/ROM:
  • Mild loss of extension.
  • MCL may show laxity.
  • Sometimes there is crepitus.

DIAGNOSIS

X-ray

Projections: AP and lateral of the elbow. If the AP is normal, one can do an AP with the elbow in 45° of flexion.
Findings: Well-defined irregularities, flattening and/or fragmentation. There is a localized area in capitellum with rareification and crater formation.
  • With Panner disease there is an irregular epiphysis.

Magnetic Resonance Imaging (MRI)

MRI is most useful for assessing the size, the extent of edema and cartilage status. Early OCD will show a discrete area of low signal intensity on T1 images. The T2 images may show no abnormalities early on.

TREATMENT

Overview

The treatment is based on the degree of lesion displacement.

Nonoperative Treatment

Indication: Type 1 lesions (stable fragments)/non-displaced lesions.
Method: Cessation of activity and gentle ROM exercises with or without immobilization during 3-6 weeks followed by slow progression back to activities over next 6-12 weeks. The patient are not allowed throwing activities until symptoms subside and full range of motion is restored.

Operative Treatment

Indication: Displaced lesions and when reduction of activities and physical therapy do not improve symptoms.
  • Specific indications for arthroscopy: Frequent locking, persistent flexion contracture, pain, despite participating in physical therapy.
Method: Arthroscopic debridement.

Operation Methods

Arthroscopic microfracture or drilling of capitellum
Indication:
  • Unstable type 1 lesions.
  • Stable type 2 lesions.
Technique: Microfracture of chondral lesion or extra- or transarticular drilling of defects.
Post operative treatment:
  • Protected early range of motion.
  • Strengthening at 2 months.
  • Throwing and weight bearing at 4-6 months.
 
Fixation of lesion
Indication: Large lesions that are incompletely displaced.
Technique: Arthroscopic reduction and fixation.
Post operative treatment:
  • Protected early range of motion.
  • Strengthening at 2 months.
    Throwing and weight bearing at 4-6 months.
 
Arthroscopic debridement and loose body excision
Indication:
  • Unstable type 2 lesion.
  • Type 3 lesions.
Post operative treatment:
  • Early range of motion with or without brace.
  • Begin strengthening when range of motion is pain free.
  • No throwing or weight bearing activities for 3 months.

Osteochondral autograft or allograft transplantation surgery (OATS)
Indication
  • Large type 2and 3 capitellar lesions which engage the radial head.
  • Uncontained lesions may require size-matched fresh allograft.
Post operative treatment
  • Early range of motion.
  • Resistive/strengthening exercises at 3 months.
  • Progressive throwing program begins at 5 months through 7 months.

COMPLICATIONS AND PROGNOSIS

Complications

  • Elbow stiffness and pain.
  • Unable to return to sports.
  • Osteoarthritis.

Prognosis

  • Prognosis is based on physeal status. Juvenille OCD better prognosis than adult.
  • Most lesions heal between 6 to 18 months of nonoperative treatment.
  • There is a wide range of potential disability with inability to participate in sports at same level and up to 50% develop osteoarthritic changes in the long term.
  • Osteonecrosis of the capitellum (Panner disease) has a relatively benign course.
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References