Panner Disease (Pediatric)

Synonyms
Osteochondrosis of the capitulum, Panner's disease

INTRODUCTION

Definition

Osteochondrosis of the capitulum that leads to similar changes to those observed in Legg Calve Perthes disease.
  • It is important to distinguishe Panner disease from osteochondritis dissecans (OCD) of the elbow which also affects the capitellum.

Epidemiology

  • The condition occurs almost always in the dominant elbow.
  • It affects children between 5 and 12 years of age.
    • OCD occurs in older children or adolescents (older than age 13 years).
  • Most common in boys. It is believed that the reason for this is due to delayed appearance and maturation of the secondary growth centers.

Etiology

Unknown etiology. It might be due to chronic repetitive trauma, congenital and hereditary factors, embolism (fat), and endocrine disturbances. 
  • Abnormal valgus stress after the age of 5 years might be the most important factor in the development of Panner disease.

Pathogenesis

There is a rich vascular supply of the capitellum prior to the age of 5 years. Afterwards, the nucleus of the capitellum is mainly supplied by posterior vessels functioning as end arteries. These arteries might be disrupted by repetitive stress (i.e. throwing) och ischemia might develop, which can lead to disordered endochondral ossification.

CLINICAL FEATURES

Symptoms

The child might have several weeks of intermittent pain and stiffness in the affected elbow, often with a history of valgus stress. The symptoms are relieved by rest and aggravated by activity. The duration of symptoms varies from a few months to 2 years.

Signs

Inspection: A small effusion and swelling may be noted.
Palpation: Local tenderness over the lateral aspect of the elbow. 
Movement/ROM
  • There is typically limited extension (lacking 20-30° of full extension). Loss of flexion is less common.
  • There may be slight loss of pronation and supination.

DIAGNOSIS

X-ray

Early on, the capitulum appears irregular with areas of radioluceny, which indicates resorption, and sclerosis. Later the radiographs show larger radiolucent areas followed by reconstruction of the bony epiphysis.

Magnetic Resonance Imaging (MRI)

Usually the entire capitulum is affected and demonstrates low T1 signal and high T2 signal.

TREATMENT

Overview

The treatment is nonoperative.

Nonoperative Treatment

Indication: Most cases.
Method: Symptomatic treatment with reduction of elbow activities that increase valgus stress. Sometimes the child can use a long arm cast or splint for 3-4 weeks until pain, swelling, and local tenderness subside. Non-steroidal anti-inflammatory drugs (NSAID) may provide relief.
  • The epiphysis usually becomes revascularized and develops normal configuration why nonoperative treatment is sufficient.
  • Observe that the radiographic resolution may lag behind the clinical recovery of symptoms.

Operative Treatment

Surgery is contraindicated for Panner disease (unlike OCD elbow).

COMPLICATIONS AND PROGNOSIS

Prognosis

There is usually a benign self-limiting course. A slight loss of elbow extension may persist in some patients.
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