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Osteochondritis Dissecans of Elbow

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Topic updated on 02/07/15 5:17pm
Introduction
  • A localized injury and subsequent separation of articular cartilage and subchondral bone of the capitellum  
  • Epidemiology
    • demographics
      • usually occurs after age 10 (typically adolescents)
      • juvenille OCD better prognosis than adult
      • boys more common than girls
    • location
      • typically located in capitellum of dominant upper extremity
    • risk factors 
      • repetitive overhead and upper extremity weight bearing activities
        •  gymnasts and throwing 
  • Pathophysiology 
    • theorized to result from repetitive compression-type injury (overhead or upper extremity weight bearing activities) of the immature capitellum causing 
      • vascular insufficiency
      • repetitive microtrauma
  • Associated conditions
    • Panner disease
      • typically presents in first decade of life (<10 years old)
      • usually benign self-limiting course
      • same mechanism of injury as OCD
  • Prognosis
    • most heal between 6 to 18 months of nonoperative treatment
    • wide range of potential disability 
      • inability to participate in sports at same level
      • long term arthritic changes
Classification
 
Radiographic and Arthroscopic Classification
Type I Intact cartilage 
Bony stability may or may not be present
Type II Cartilage fracture with bony collapse or displacement 
Type III Loose bodies present in joint  
 
Presentation
  • Symptoms
    • elbow pain
      • insidious, activity-related onset of elbow pain in dominant arm
      • may be localized laterally 
    • mechanical symptoms
      • catching
      • locking
      • grinding
      • motion restriction
  • Physical exam
    • tenderness over lateral elbow
    • mild loss of motion
    • possible effusion of elbow joint q
      • usually mild
    • may or may not present with crepitus
Imaging
  • Radiographs
    • recommended views
      • AP and lateral of the elbow 
    • findings
      • plain radiographs can confirm the diagnosis based on bone defect 
      • capitellum is most commonly involved
      • Panner disease exhibits an irregular epiphysis, OCD a well-defined subchondral lesion
  • MRI
    • most useful for assessing:
      • size
      • extent of edema
      • cartilage status
Treatment
  • Nonoperative
    • cessation of activity +/- immobilization
      • indications
        • type I lesions (stable fragments)
      • technique
        • 3-6 weeks followed by slow progression back to activities over next 6-12 weeks
      • outcomes
        • >90% success rate
  • Operative
    • diagnostic arthroscopy and drilling of capitellum
      • indications (separated fragments)
        • unstable type I lesions
        • stable type II lesions
      • technique
        • arthroscopic reduction
        • microfracture of chondral lesion
        • extra- or transarticular drilling of defects
      • post op care
        • protected early range of motion
        • strengthening at 2 months 
        • throwing and weight bearing at 4-6 months
      • outcomes
        • good success rate 
    • fixation of lesion
      • indications
        • large lesions that are not completely displaced
      • post op care
        • protected early range of motion
        • strengthening at 2 months
        • throwing and weight bearing at 4-6 months
      • outcomes
        • highly variable
    • debridement and loose body excision
      • indications
        • unstable type II lesion
        • type III lesions
      • post op care
        • early range of motion +/- brace
        • begin strengthening when range of motion is painfree
        • no throwing or weight bearing activities X 3 months 
Complications
  • Elbow stiffness
  • Pain
  • Unable to return to sports
  • Arthritis

 

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Qbank (1 Questions)

TAG
(OBQ08.258) A 13-year-old pitcher develops pain over the lateral aspect of his throwing elbow. He has an effusion and a painful click on passive elbow rotation. What is the most likely diagnosis? Topic Review Topic

1. Tommy John lesion
2. Postero-lateral rotatory instability
3. Osteochondritis dissecans
4. Stress fracture
5. Plica syndrome

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