OSTEOCHONDRITIS DISSECANS OF THE HUMERAL CAPITELLUM: Diagnosis and Treatment

doi:10.1016/S0278-5919(05)70270-2

Clinics in Sports Medicine

Volume 20, Issue 3, 1 July 2001, Pages 565-590

https://doi.org/10.1016/S0278-5919(05)70270-2 Get rights and content

Repetitive use injuries can be difficult to understand and solve in the adult. Add the dimension of a metabolically active physis and epiphysis, and the complexity of the situation increases geometrically. Our ability to tease apart the sequence and understand the inciting factors responsible for the maladies affecting the immature elbow is predictably limited in this complex situation. An effort should be made to be precise when speaking about elbow diagnoses and pathology. Poorly chosen terms and “umbrella” diagnoses create confusion. The term “Little Leaguer's elbow” is one such term. To some, it means traction apophysitis of the olecranon; to others, it means medial epicondyle avulsion; and to still others, it means osteochondritis dissecans. “Little League elbow” now encompasses a series of diagnoses including (1) medial epicondylar fragmentation and aphophysitis, (2) delayed or accelerated apophyseal growth of the medial epicondyle, (3) delayed closure of the medial epicondylar growth plate, (4) osteochondrosis and osteochondritis dissecans of the humeral capitellum, (5) deformation and osteochondritis of the radial head, (6) hypertrophy of the ulna, and (7) olecranon apophysitis.1, 5, 16, 17, 54, 55

Osteochondritis dissecans (OCD) of the capitellum occurs in immature athletes and is rarely found in adults. OCD is a localized injury or condition of the subchondral bone, resulting in loss of support for the overlying articular cartilage and breakdown and fragmentation of the cartilage and underlying bone.⁴¹ OCD has remained the center of much discussion and debate, principally because of controversy over its etiology and our inability to treat this malady and alter its poor long-term prognosis. Various theories have been proposed, but no single etiology is universally accepted.⁴⁴ The original description and naming of the lesion was attributed to König.²⁹ The term is somewhat inaccurate: it implies inflammation of the bone and cartilage, yet no inflammatory cells have been shown on histologic sections of excised fragments or surrounding synovium.34, 46 The term dissecans, however, comes from the Latin dissec—to separate—and accurately describes the separation of osteochondral fragments in the late stages of the process.

Treatment has evolved from removal of loose bodies (first described more than 150 years ago³⁹) to current nonoperative treatment,23, 51, 52 arthroscopic debridement,3, 43 arthroscopic subchondral drilling,36, 51, 52 open drilling,18, 25 abrasion chondroplasty,²⁴ and internal fixation with bone pegs³⁶ and bioabsorbable or metal screws.22, 28 Most authors would agree there is no indication for reduction and fixation of loose bodies. Excision of the fragment only, with debridement of the bed, is the mainstay of treatment.3, 23, 31, 36, 43, 51, 52 Long-term results have shown that about half of affected persons in adolescence will develop symptomatic degenerative joint disease.⁵² Magnetic resonance (MR) imaging with and without contrast has been shown to help with early detection,⁵³ which could allow for earlier intervention and improved long-term outcome.⁵³ Although most of the attention in the orthopaedic literature focuses on OCD of the capitellum, the process also has been reported in the trochlea,⁵⁷ radial head, and olecranon.4, 12

Section snippets

ETIOLOGY

The precise etiology of OCD of the humeral capitellum has not been universally agreed on. It is agreed, however, that two disorders of the humeral capitellum occurring in immature individuals present with similar radiographic findings: Panner's disease and OCD. The age of presentation and prognosis of the conditions are different, and therefore they should be distinguished as separate but related entities. Panner's disease typically presents between 7 and 12 years of age, with a peak age of 9

HISTORY

The typical patient is an adolescent baseball pitcher between 11 and 15 years of age who has been pitching for 3 to 5 years before symptoms began.⁵³ Patients often seek medical attention only after several months of pain.23, 53 Pain is often localized to the lateral aspect of the elbow and relieved by rest. Catching or locking of the elbow are late symptoms indicative of articular cartilage fragmentation and loose body formation.52, 53 Pain can be absent or poorly localized; presenting symptoms

EXAMINATION

Tenderness laterally over the radio–capitellar joint is often present but can be poorly localized. Loss of extension is more common than loss of flexion; however, early in the disease process, full motion can still be present.⁵³ Provocative maneuvers include the “active radio–capitellar compression test.”⁴¹ This involves having the patient pronate and supinate the forearm in full extension. Compression across the radio–capitellar joint from muscular forces may reproduce symptoms.⁴¹

DIAGNOSTIC EVALUATION

Radiographs are the initial diagnostic test of choice. Elbow centers of ossification characteristically appear in a specific order: the capitellum (1 to 2 years), followed by the radial epiphysis (3 to 4 years), the medial epicondyle (5 to 6 years), the trochleas (9 to 10 years), the lateral epicondyle (more than 10 years), and the common epiphysis (Fig. 6). Recently, Cheng et al elucidated ethnic variability by documenting that the trochlear ossification center appears after the olecranon in

REVIEW OF THE LITERATURE

Interpreting the literature is fraught with difficulty. Studies often do not distinguish between very early, early, and late OCD. No universally accepted classification exists, and not all studies include MR imaging findings. In addition, surgical techniques have changed dramatically over the last 15 years. Therefore, comparisons of more recent studies with historical studies is difficult.

Traditional treatment has centered on identifying one of the three basic types of lesions: stable, attached

TREATMENT GUIDELINES

When treating a skeletally immature athlete with elbow pain, one must strongly suspect OCD, particularly if the athlete is a pitcher or gymnast. Our approach to this problem is still evolving because the best imaging modality and treatment have not been determined. The following is meant as a guide and not the only approach to OCD of the elbow in the immature athlete.

We recommend obtaining anterior–posterior and lateral radiographs of the elbow. Radiographs that are negative or have very subtle

Imaging

Several controversies currently exist in the diagnosis and treatment of OCD of the humeral capitellum. The use of gadolinium intravenously or intra-articularly to assess fragment viability and stability remains a subject of debate. Traditional treatment consists primarily of removal of loose bodies and debridement of the lesion.⁴⁸ This approach is supported by the literature; however, most of the studies on which this approach is based do not reflect the newer diagnostic or treatment

SUMMARY

Elbow pain seen in the at-risk athlete, such as a baseball player (in particular, a pitcher) or gymnast, should raise suspicion for OCD. OCD of the humeral capitellum remains a difficult problem to treat. Once radiographic changes are obvious, long-term studies suggest that half of affected individuals will be symptomatic. Currently, the key to successful treatment is early detection. Gymnasts, in general, fare worse in returning to sport. The reason is not entirely clear but is likely related

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