Shoulder and Elbow cases elbow osteochondritis dissecans

A 14-year-old baseball pitcher presents to the office with left throwing elbow pain for the past two months when he throws or lifts weights. Examination reveals lateral joint line tenderness with no detectable effusion and full range of motion without crepitation. Moving valgus stress test does not elicit pain. His elbow radiograph is shown below (Fig. 2–111).

 

 

 

Figure 2–111

 

What is the next most appropriate treatment?

1. Elbow arthroscopy, debridement of the lesion

2. Arthroscopic drilling of the lesion

3. Ulnar collateral ligament repair

4. Corticosteroid injection of the elbow

5. Cessation of throwing activities

 

Discussion

The correct answer is (E). This patient has osteochondritis dissecans (OCD) of the capitellum. He has not undergone any conservative treatment. Stable, nondisplaced lesions can heal spontaneously with rest and discontinuation of throwing. Surgical treatment is reserved for unstable lesions or loose bodies. This patient’s

examination is not consistent with an ulnar collateral ligament (UCL) injury. Little league elbow is another commonly encountered diagnosis in this patient population, but like UCL injuries, manifests with medial sided pain after throwing.

Besides baseball, what other sport is this condition most commonly seen with?

1. Football linemen

2. Rugby players

3. Rowers

4. Gymnasts

5. Swimmers

 

Discussion

The correct answer is (D). The exact etiology and natural history of osteochondritis dissecans of the capitellum is poorly understood. It is mainly encountered in adolescent age groups, although with earlier youth sports participation, it is now seen in younger athletes as well. It most commonly develops in female gymnasts as well as in the throwing elbow of male pitchers, as both of these sports involve repetitive loading of the elbow joint.

Which of the following findings differentiates Panner’s disease from osteochondritis dissecans of the capitellum?

1. Site of involvement within the elbow

2. Extent of capitellar involvement

3. Symptoms may resolve with conservative management

4. Collateral ligament instability

 

Discussion

The correct answer is (B). Panner’s disease is a separate disorder of the immature capitellum that must be distinguished from OCD. Panner’s disease usually arises in patients younger than 10 years of age, whereas OCD lesions of the capitellum typically arise after age 11. Both disorders involve the capitellum, causing lateral joint tenderness. Whereas OCD of the capitellum represents a focal injury of the cartilage and subchondral bone, Panner’s disease is idiopathic chondrosis and fragmentation of the entire capitellum. Both conditions can resolve with conservative treatment and are not dependent on collateral ligament instability.

What is the suspected etiology of capitellar osteochondritis dissecans?

1. Nutritional deficiency

2. Infection

3. Traumatic and vascular

4. Congenital

5. Malignancy

 

Discussion

The correct answer is (C). While the exact etiology of OCD lesions of the capitellum is poorly understood, trauma and ischemia are suspected to play a significant role. OCD occurs in overhead throwing athletes and female gymnasts, supporting the theory that repetitive trauma serves as an inciting event. The capitellum receives its blood supply from posterior end-arteries that traverse the growth plate, without metaphyseal collateral contribution. This tenuous vascular anatomy implicates an ischemic contribution to OCD. Several case studies have reported on familial or hereditary predisposition to OCD; however, the condition is not present at birth.

The patient undergoes conservative management consisting of rest, anti-inflammatory medications, and physical therapy. After six months, he is still not able to return to play and has progressively worsening symptoms with attempted throwing. He has a moderate elbow effusion as well as a 20-degree flexion contracture. An elbow MRI arthrogram is obtained and shown (Fig. 2–112). He elects to proceed with elbow arthroscopy. Intraoperative arthroscopic images are shown (Figs. 2–113 and 2–114).

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Figure 2–112

 

 

 

 

 

Figure 2–113

 

 

 

Figure 2–114

 

Which of the following is the most commonly reported complication of elbow arthroscopy?

1. Contracture

2. Compartment syndrome

3. Septic joint

4. Neuropraxia

5. Vessel injury

 

Discussion

The correct answer is (D). The overall reported rate of transient and permanent complications after elbow arthroscopy is around 10% and is much higher than the rate after knee and shoulder arthroscopy (1–2%). The overall most commonly reported complication is prolonged drainage or erythema around portal sites. The lateral portal sites are susceptible to this issue as the joint is relatively subcutaneous in this area, and there is scant tissue to act as a barrier. Deep infection, while being the most serious postoperative complication, is relatively rare (0.8%). In one series, the rate of transient neurological injuries was found to be 2%. These result from compression, local anesthetic injection, and direct trauma. A thorough understanding of the neurovascular anatomy of the elbow is crucial to achieve proper portal placement. Loss of elbow motion was reported in approximately 1% of cases and is usually minor (less than 20 degrees).

 

Objectives: Did you learn...?

 

Recognize the clinical and radiographic presentation of elbow osteochondritis dissecans?

 

 

Formulate a differential diagnosis for pediatric sports elbow injuries? Treat elbow osteochondritis dissecans?