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Updated: Feb 4 2024

Osteochondritis Dissecans of Elbow

Images
https://upload.orthobullets.com/topic/3085/images/Case A - xray AP 2_moved.jpg
https://upload.orthobullets.com/topic/3085/images/type 1 ocd.jpg
https://upload.orthobullets.com/topic/3085/images/capitellar ocd.jpg
https://upload.orthobullets.com/topic/3085/images/ocd-lesion-xray.jpg
https://upload.orthobullets.com/topic/3085/images/lateral elbow.jpg
  • summary
    • Osteochondritis Dissecans of Elbow is a localized injury and subsequent separation of articular cartilage and subchondral bone of the capitellum, most commonly seen in gymnasts and pitchers. 
    • Diagnosis can be made with plane radiographs but MRI studies can be helpful to evaluate for the size of lesion and extent of bony edema. 
    • Treatment can be nonoperative or operative depending on size of the lesion, stability of the lesion, and presence of loose bodies.
  • Epidemiology
    • Demographics
      • usually occurs after age 10 (typically adolescents)
      • juvenille OCD better prognosis than adult
      • boys more common than girls
    • Anatomic location
      • typically located in capitellum of dominant upper extremity
    • Risk factors
      • repetitive overhead and upper extremity weight bearing activities
        • gymnasts and throwing
  • Etiology
    • 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)
  • 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
        • 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
  • 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
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