High Yield Topics

Panner Disease and OCD of Elbow Capitellum

By admin



Ovid: 5-Minute Sports Medicine Consult, The


Panner Disease and OCD of Elbow Capitellum
John J. Wilson
Nadim Ilbawi
Basics
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.
Description
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.
Epidemiology
  • 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.
Genetics
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
Etiology
  • 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
Diagnosis
History
  • 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
Lab
Not indicated unless other underlying etiology suspected (eg, infectious, endocrine)
Imaging
  • 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

P.439


Treatment
Medication
Analgesics and NSAIDs may be used as necessary for pain relief.
Additional Treatment
Little evidence exists for duration of treatment, bracing, or physical therapy for these conditions:
  • Panner's disease:
    • Rest from offending activities and avoidance of radiocapitellar joint loading for 3–6 mos
    • Immobilization for 3–4 wks may provide early pain relief.
    • Nonoperative treatment provides excellent long-term prognosis.
    • Surgery rarely necessary
  • OCD of the capitellum:
    • Rest from offending activities and avoidance of radiocapitellar joint loading for 3–6 mos:
      • Some advocate for hinged unloader elbow brace to avoid excessive valgus stress.
    • Immobilization for 3–4 wks may provide early pain relief.
    • Nonoperative treatment is recommended for early, intact, and stable lesions.
    • Conservative monitoring with serial radiographs is reasonable in skeletally immature patients, often with successful resolution of stable OCD lesions over a period of weeks to months.
    • Patients with stage 3–4 lesions on MRI, particularly in the presence of a loose body, is an indication for early surgical referral.
    • In skeletally mature patients with symptomatic OCD, early referral for surgical consultation is recommended.
Referral
  • Panner's disease:
    • Persistent pain or symptoms despite appropriate conservative care
  • OCD of the capitellum:
    • Persistent pain or symptoms despite appropriate conservative care
    • Symptomatic loose bodies
    • Articular cartilage fracture
    • Unstable, loose, or displaced osteochondral lesion
Surgery/Other Procedures
  • Operative management is indicated for the following reasons (2)[C]:
    • Failure of appropriate conservative management
    • Mechanical symptoms
    • Intra-articular loose bodies
    • Unstable lesions
  • Operative techniques vary, include the following:
    • Loose body or unstable fragment removal
    • Fixation of unstable osteochondral fragment
    • Chondroplasty
    • Autologous chondrocyte implantation
    • Subchondral drilling
    • Closing wedge osteotomy of the lateral epicondyle
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.
Prognosis
  • 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
Complications
  • Many patients will have persistent loss of extension despite good clinical outcome with return to sport.
  • Early degenerative joint disease and continued symptoms of pain and stiffness are more likely in advanced cases.
References
1. Kijowski R, De Smet AA. MRI findings of osteochondritis dissecans of the capitellum with surgical correlation. AJR Am J Roentgenol. 2005;185:1453–1459.
2. Baker CL, Romeo AA, Baker CL. Osteochondritis dissecans of the capitellum. Am J Sports Med. 2010.
3. Kobayashi K, Burton KJ, Rodner C, et al. Lateral compression injuries in the pediatric elbow: Panner's disease and osteochondritis dissecans of the capitellum. J Am Acad Orthop Surg. 2004;12:246–254.
Codes
ICD9
732.3 Juvenile osteochondrosis of upper extremity
Clinical Pearls
  • Panner's disease and OCD of the elbow capitellum are common causes of elbow disability in young adolescent athletes.
  • Repetitive overuse of the elbow, such as in throwing sports, gymnastics, and weightlifting, are known risk factors.
  • Clinical suspicion warrants evaluation with plain radiographs and MRI.
  • Early, stable lesions can be treated with prompt rest and nonoperative treatment with favorable results and return to activity.
  • Patients with advanced unstable lesions, loose bodies, mechanical symptoms, or failed conservative management are candidates for operative treatment.


Continue Reading
You might also like More from author

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More