Osteochondritis Dissecans - Elbow

Key Points:

  • Look for loose bodies in the radial fossa, coronoid fossa, and olecranon fossa
  • Throwers, overhead athletes, and upper extremity weight bearing athletes (gymnasts) are at higher risk of capitellum OCD lesions. 
  • Must distinguish from Panner’s Disease, transient osteonecrosis of the capitellum which typically occurs at younger ages, 5-12yo.
  • Contained lesions seem to have better outcomes than uncontained lesions. 

Description:

Osteonecrosis of subchondral bone in the capitellum. Can be stable (intact cartilage cap) or unstable (disrupted cartilage cap, completely separated fragment, loose body).

Epidemiology:

Most often seen in adolescents 12 to 16 years old who are overhead athletes, throwing athletes, or upper extremity weight bearing athletes.  Baseball and gymnastics are common sports for patients with capitellar OCD lesions. It is thought to be due to repetitive microtrauma to the capitellum with valgus elbow loading. 

Baseball players who start playing at an earlier age, play for longer periods of time and have elbow pain are at increased risk for OCD lesions of the capitellum.

Clinical Findings:

Pain is often vague and activity related with an insidious onset. Tenderness to the lateral elbow over the capitellum, elbow effusions, limitation of pronation/supination, and lateral pain with valgus loading of the elbow may be present. Patients may report mechanical symptoms including locking or range of motion limitations if loose bodies are present. 

Imaging Studies:

AP, lateral, and oblique elbow radiographs are the initial imaging of choice.  The Minami classification is based on plain radiographs: type 1 has flattening or cystic changes of the capitellum, type 2 has clear detachment or fragment splitting of the capitellum. MRI should be obtained to determine lesion size, location, stability, cartilage integrity and loose bodies. High signal indicating fluid behind the lesion is most predictive of an unstable lesion. Contained lesions (lesions with an intact lateral wall) seem to have improved outcomes in comparison to uncontained lesions. 

Etiology:

Treatment:

Management is similar to OCD lesions of the knee and ankle. Nonoperative management is primarily reserved for skeletally immature patients with stable lesions. Skeletal maturity, unstable lesions or lesions that have failed to heal with nonoperative management can be considered for surgical intervention. Typically, elbow arthroscopy can be used for debridement, drilling, fixation, or removal of loose bodies. An arthrotomy may be required for fixation and osteochondral allograft or autograft implantation. Arthroscopic intervention commonly utilizes 30 and 70 degree arthroscopes. It can be conducted with supine, lateral or prone positioning based on surgeon preference.

Video on POSNAcademy demonstrating OATS procedure for Capitellar OCD

Complications:

Short term complications include nonunion/nonhealing of the OCD lesion, hardware removal if pin fixation used, and loose body damage throughout the elbow. Long term complication includes osteoarthritis. 

Complications from elbow arthroscopy approach 10% including neurologic injuries both permanent and transient, hematoma, fistula, arthrofibrosis, reflex sympathetic dystrophy, and heterotopic ossification.

References:

  1. Dexel J, et al. Comparative study of elbow disorders in young high-performance gymnasts. Int J Sports Med Oct 2014; 35(11):960-5
  2. Iwasaki N, et al. A retrospective Evaluation of Magnetic Resonance Imaging Effectiveness on Capitellar Osteochondritis Dissecans Among Overhead Athletes. Am J Sports Med. 2012; 40:624-630
  3. Kida Y, et al. Prevalence and Clinical Characteristics of Osteochondritis Dissecans of the Humeral Capitellum among Adolescent Baseball Players.  Am Journal Sports Med 2014;42(8):1963-1971
  4. Kosaka M, et al. Outcomes and Failure Factors in Surgical Treatment of Osteochondritis Dissecans of the Capitellum. J Pediatr Orthop.2 013;33:719-724
  5. Satake H, et al. Preoperative Imaging Criteria for Unstable Osteochondritis Dissecans of the Capitellum. Clin Orthop Relat Res. 2013; 471:1137-1143
  6. Shi LL, et al. Contained versus Uncontained Lesions in Juvenile Elbow Osteochondritis Dissecans. J Pedaitr Orthop. 2012;32:221-225
  7. Smith MV, Bedi A, Chen NC. Surgical Treatment for Osteochondritis Dissecans of the Capitellum. Sports Health. Sept-Oct 2012; 4(5): 425-432
  8. Tis JE, et al. Short-term results of Arhtroscopic Treatment of Osteochondritis Dissecans in Skeletally Immature Patients. J Pediatr Orthop. 2012;32:226-231

Top Contributors:

Jennifer Beck MD