Review Question - QID 220124

The patient has capitellar osteochondritis dissecans (OCD) in addition to a normal-variant os supratrochleare dorsale (Illustration A). The best prognostic indicator for healing of a symptomatic OCD lesion is the presence of open physes, which this patient no longer has (Answer 4).

Capitellar osteochondritis dissecans (OCD) lesions are common in young repetitive overhead and upper extremity weight-bearing athletes, such as gymnasts. The lesions are theorized to result from repetitive compression-type injury (overhead or upper extremity weight-bearing activities) of the immature capitellum causing vascular insufficiency and subsequent separation of articular cartilage and subchondral bone of the capitellum. Diagnosis can be made with plain radiographs but MRI studies can be helpful in evaluating for the size of the lesion and extent of bony edema. Treatment can be non-operative or operative depending on the size of the lesion, stability of the lesion, and presence of loose bodies, with most lesions healing between 6 to 18 months of non-operative treatment in the skeletally immature population with open physes.

Niu et al. reviewed the predictors of treatment success in the non-operative management of stable pediatric osteochondritis dissecans of the capitellum. The authors retrospectively reviewed 89 patients younger than 19 years who presented with stable OCD of the capitellum and were treated non-operatively for a minimum of 2 months. They found that over half of stable capitellar OCD lesions have the potential to heal with activity restriction alone. They concluded that smaller lesions without cystic-like lesions are more likely to heal with non-operative treatment.

Funakoshi et al. reviewed the predictors of unsuccessful non-operative management of capitellar osteochondritis dissecans lesions. The authors included 245 elbows with capitellar OCD, divided into 3 groups comprising 148 elbows requiring an immediate operation on initial examination, 48 requiring nonsurgical treatment, and 49 requiring an operation after non-operative management. They found that radial head enlargement and skeletal age difference were significantly associated with a lack of spontaneous healing, leading them to conclude that spontaneous healing in the moderate stage can be predicted with plain radiographs used to evaluate radiocapitellar congruity and skeletal age.

Figure A and B are AP and lateral radiographs of the elbow showing flattening of the capitellum in a skeletally mature individual with the incidental presence of an os supratrochleare dorsale, which represents a normal anatomic-variant. Illustration A demonstrates the capitellar OCD with a blue arrow and the Os with a yellow arrow.

Incorrect Answers:
Answers 1-3 and 5: The patient's skeletal age and lack of open physes represents the most relevant prognostic indicator for healing. The other factors do not play as dominant a role in predicting healing with non-operative management.