Panner Disease and OCD of Elbow Capitellum

Ovid: 5-Minute Sports Medicine Consult, The

Panner Disease and OCD of Elbow Capitellum
John J. Wilson
Nadim Ilbawi
Panner's disease and osteochondritis dissecans, conditions of the pediatric elbow, are commonly the result of overuse, particularly in the young throwing athlete and gymnasts.
Panner's disease (osteochondrosis) and osteochondritis dissecans (OCD) of the capitellum are overuse injuries of the elbow found in children and adolescents (respectively) that involve disordered endochondral ossification of the humeral capitellum.
  • Occur most commonly in the dominant arm
  • Boys affected more often than girls
  • Panner's disease occurs most commonly before the age of 10
  • OCD of the capitellum mainly in adolescents:
    • Average patient age is between 12 and 17 yrs
  • <5% are bilateral
  • Lesions of the capitellum are most common, but disorders of the radial head, trochlea, olecranon, and olecranon fossa have also been described.
Risk Factors
  • Precise etiology is not well established.
  • Lateral compression and shear forces are applied to the radiocapitellar joint during the late cocking and early acceleration phases of throwing and racquet sports.
  • Increased weight-bearing and axial impact loads across the upper extremity are seen in young gymnasts and weightlifters.
  • Repetitive compressive forces may compromise vulnerable blood supply to capitellum and result in articular cartilage breakdown and fragmentation of subchondral bone.
A genetic predisposition has been hypothesized.
General Prevention
  • Proper throwing technique in overhead throwing athletes
  • Adequate rest from activities that cause repetitive microtrauma to the lateral elbow
  • Panner's disease:
    • Articular osteochondrosis
    • Articular chondrocyte viability may be compromised by repetitive compressive loading.
    • Ossific nucleus of capitellum has a tenuous blood supply, which may be vulnerable to stresses at the elbow.
  • OCD of the elbow capitellum:
    • Disordered growth of articular cartilage and subchondral bone resulting in spontaneous osteonecrosis and formation of osteochondral fragments
    • Histopathological examination has failed to demonstrate inflammatory reaction.
    • Likely a result of repetitive compressive forces exerted across the radiocapitellar joint during a time of epiphyseal vulnerability
  • Often insidious onset of elbow pain with activity:
    • Acute, sudden onset is rare.
  • Pain is relieved with rest.
  • Pain is often lateral, but diffuse pain can occur.
  • Restricted range of motion is common.
  • Other symptoms: Stiffness, swelling, clicking, catching, grinding, locking
Physical Exam
  • Tenderness over radiocapitellar joint
  • Loss of extension; 15–30° is common:
    • Loss of flexion less common
    • Pronation, supination usually unaffected
  • Effusion may be present.
  • Crepitus may be present with active or passive pronation and supination.
  • Pain with radiocapitellar compression test:
    • Arm actively pronated and supinated with elbow fully extended
Diagnostic Tests & Interpretation
Not indicated unless other underlying etiology suspected (eg, infectious, endocrine)
  • Plain radiographs:
    • Obtain anteroposterior and lateral elbow radiographs:
      • May be compared to contralateral elbow to detect subtle changes of capitellum
      • Able to demonstrate interval healing
    • Panner's disease: Fissuring, radiolucency, decreased size, flattened articular surface, sclerosis, and loose bodies may be visualized at capitellum:
      • Grade I: Translucent shadow in middle or lateral capitellum
      • Grade II: Clear line or demarcation between lesion and subchondral bone
      • Grade III: Presence of loose bodies
    • OCD of capitellum:
      • Focal lucency in subchondral bone in anterolateral capitellum
      • Similar appearance to Panner's; loose bodies and capitellar flattening more common in OCD
    • Low sensitivity to detect OCD and loose bodies; 66% and 57%, respectively:
      • MRI considered standard imaging modality for additional assessment.
  • MRI (1):
    • Imaging modality of choice
    • Capable of detecting early lesions not visible on plain radiographs
    • Useful for lesion characterization of size and extent
    • Allows assessment of lesion stability and integrity of articular cartilage:
      • Unstable lesions demonstrate peripheral ring of high-signal intensity or an underlying fluid-filled cyst on T2-weighted images
    • Able to demonstrate interval healing and lesion resolution
  • CT arthrography:
    • Useful for confirming presence of intra-articular loose bodies
    • Depicts cartilage integrity and fissuring
  • US:
    • Able to assess subchondral bone and overlying cartilage integrity
    • Operator-dependent imaging modality
  • Radionucleotide bone scan:
    • Very sensitive, but nonspecific for Panner's and OCD of the capitellum
    • Limited usefulness in the diagnosis and staging of these conditions
Diagnostic Procedures/Surgery
Elbow arthroscopy allows direct visualization of the articular cartilage surface for staging:
  • May fail to identify changes of the capitellum not evident at joint surface
Differential Diagnosis
  • Trochlear lesions (avascular necrosis, osteochondritis dissecans of the elbow trochlea)
  • Distal humerus fracture
  • Posterolateral elbow impingement
  • OCD of the radial head
  • Angular deformity of the radial neck


Ongoing Care
Follow-Up Recommendations
Patient Monitoring
Return to activity:
  • Gradual progressive return to activity and sports can begin after a period of rest when patient is asymptomatic.
  • Physical therapy may begin when symptoms improve:
    • Range of motion, stretching, and gentle strengthening while avoiding radiocapitellar stress
  • Evidence of healing should be evident on follow-up radiographs or MRI before return of elbow loading:
    • Serial radiographs performed at 6-wk intervals are useful to document healing or progression.
    • MRI follow-up 6 mos after initiation of conservative management to document lesion healing; consider imaging at 1 yr
  • Athlete should be monitored closely by health care team during return to sport:
    • Progress activity as tolerated, gradually increasing weight-bearing and load across lateral elbow.
    • Rest and resumption of activity avoidance if symptoms return
  • For pitchers, recommend strict adherence to established pitch count recommendations.
  • It is important to establish good core strength to improve sport mechanics and potentially decrease loading of the radiocapitellar joint.
Patient Education
  • Instruct patients on importance of proper sport technique.
  • Strict adherence to pitch counts upon return to pitching
  • Re-evaluation is necessary for return of elbow symptoms after return to sport.
  • Consider activity modification to decrease elbow loading following recovery.
  • Favorable prognostic factors (3)[C]:
    • Open capitellar physis
    • Age <10
    • Normal elbow range of motion
    • Absence of mechanical symptoms
    • Stable lesion with radiographic findings of subchondral lucency or flattening
  • Poor prognostic factors:
    • Closed capitellar physis
    • Age >10
    • Loss of elbow extension
    • Mechanical symptoms
    • Unstable lesion or loose bodies
    • Large fragment involving >50% of capitellum
732.3 Juvenile osteochondrosis of upper extremity

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