Updated: 2/6/2018

Osteochondritis Dissecans of Elbow

Topic
Review Topic
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Questions
6
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Evidence
7
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Videos
2
Cases
1
https://upload.orthobullets.com/topic/3085/images/Case A - xray AP 2_moved.jpg
https://upload.orthobullets.com/topic/3085/images/capitellar ocd.jpg
https://upload.orthobullets.com/topic/3085/images/lateral elbow.jpg
Introduction
  • A localized injury and subsequent separation of articular cartilage and subchondral bone of the capitellum  
  • Epidemiology
    • demographics
      • usually occurs after age 10 (typically adolescents)
      • juvenille OCD better prognosis than adult
      • boys more common than girls
    • location
      • typically located in capitellum of dominant upper extremity
    • risk factors 
      • repetitive overhead and upper extremity weight bearing activities
        •  gymnasts and throwing 
  • Pathophysiology 
    • theorized to result from repetitive compression-type injury (overhead or upper extremity weight bearing activities) of the immature capitellum causing 
      • vascular insufficiency
      • repetitive microtrauma
  • Associated conditions
    • Panner's disease (osteochondrosis of the capitellum)
      • typically presents in first decade of life (<10 years old)
      • usually benign self-limiting course
      • same mechanism of injury as OCD
      • surgery is contraindicated for Panner disease (unlike OCD elbow)
  • Prognosis
    • prognosis based on physeal status
    • most heal between 6 to 18 months of nonoperative treatment
    • wide range of potential disability 
      • inability to participate in sports at same level
      • up to 50% develop arthritic changes long term
Anatomy
  • Capitellum is supplied by 2 end arteries  
    • radial recurrent artery
    • interosseous recurrent artery
Classification
 
Radiographic and Arthroscopic Classification
Type I Intact cartilage 
Bony stability may or may not be present 
Type II Cartilage fracture with bony collapse or displacement 
Type III Loose bodies present in joint  
 
Presentation
  • Symptoms
    • elbow pain
      • insidious, activity-related onset of lateral elbow pain in dominant arm
    • mechanical symptoms
      • loss of extension
        • early sign
      • catching / locking / grinding
        • late signs if loose bodies present
  • Physical exam
    • lateral elbow tenderness 
    • mild loss of extension
    • possible effusion of elbow joint q
      • usually mild
    • may or may not present with crepitus
Imaging
  • Radiographs
    • recommended views
      • AP and lateral of the elbow 
    • findings
      • plain radiographs can confirm the diagnosis based on bone defect 
      • capitellum is most commonly involved
      • Panner disease exhibits an irregular epiphysis, OCD a well-defined subchondral lesion
  • MRI
    • most useful for assessing:
      • size
      • extent of edema
      • cartilage status
Treatment
  • Nonoperative
    • cessation of activity +/- immobilization
      • indications
        • type I lesions (stable fragments)
      • technique
        • 3-6 weeks followed by slow progression back to activities over next 6-12 weeks
      • outcomes
        • >90% success rate
  • Operative
    • arthroscopic microfracture or drilling of capitellum
      • indications (separated fragments)
        • unstable type I lesions
        • stable type II lesions
      • technique
        • microfracture of chondral lesion
        • extra- or transarticular drilling of defects
      • post op care
        • protected early range of motion
        • strengthening at 2 months 
        • throwing and weight bearing at 4-6 months
      • outcomes
        • good success rate 
    • fixation of lesion
      • indications
        • large lesions that are incompletely displaced
      • technique
        • arthroscopic reduction and fixation
      • post op care
        • protected early range of motion
        • strengthening at 2 months
        • throwing and weight bearing at 4-6 months
      • outcomes
        • highly variable
    • arthroscopic debridement and loose body excision
      • indications
        • unstable type II lesion
        • type III lesions
      • post op care
        • early range of motion +/- brace
        • begin strengthening when range of motion is painfree
        • no throwing or weight bearing activities X 3 months 
    • osteochondral autograft or allograft transplantation surgery (OATS) 
      • indications
        • large type II and III capitellar lesions which engage the radial head
        • uncontained lesions may require size-matched fresh allograft
      • post op care
        • early range of motion
        • resistive/strengthening exercises at 3 months
        • progressive throwing program begins at 5 months through 7 months
Complications
  • Elbow stiffness
  • Pain
  • Unable to return to sports
  • Arthritis
 

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Questions (6)

(SAE07SM.80) A 12-year-old Little League pitcher reports lateral elbow pain and “catching.” Examination reveals painful pronation and supination and tenderness over the lateral elbow. Radiographs are shown in Figures 22a and 22b. Initial management should consist of Review Topic

QID: 8742
FIGURES:
1

rest and repeat examination and radiographs until complete healing occurs.

20%

(26/127)

2

rest and resumption of play when he is asymptomatic and examination shows restoration of painless range of motion.

65%

(82/127)

3

arthroscopic in situ drilling.

7%

(9/127)

4

arthroscopic drilling and internal fixation.

3%

(4/127)

5

arthroscopy with removal of the loose body, followed by lateral column osteotomy.

2%

(3/127)

ML 3

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PREFERRED RESPONSE 2

(OBQ08.258) A 13-year-old pitcher develops pain over the lateral aspect of his throwing elbow. He has an effusion and a painful click on passive elbow rotation. What is the most likely diagnosis? Review Topic

QID: 644
1

Tommy John lesion

4%

(137/3364)

2

Postero-lateral rotatory instability

15%

(518/3364)

3

Osteochondritis dissecans

69%

(2331/3364)

4

Stress fracture

3%

(88/3364)

5

Plica syndrome

8%

(282/3364)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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ARTICLES (10)
VIDEOS (2)
CASES (1)
Topic COMMENTS (7)
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