Clin Sports Med. In the elbow, supplemental views such as 45 degrees flexion or oblique views may help to demonstrate the lesion. Suspicion of this condition warrants investigation with proper radiographs and magnetic resonance imaging. Which form loose bodies within the joint. 32.2 ). Gymnasts, in general, fare … We also believe that if the radiographs or MRI do not show separation of the fragment with fluid between the native and progeny bone, a period of rest has a decent chance to result in a full functional recovery in at least half of cases. In the talus, 96% of lateral lesions and 62% of … Osteochondral Autograft Transfer for Capitellar Chondral and Osteochondral Defects. In the long term OCD can lead to subsequent dege… In book: Sports Injuries of the Elbow (pp.63-72) Authors: Christiaan J A van Bergen. WILMINGTON, DELAWARE . Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Osteochondritis Dissecans of the Capitellum, Lateral: Extensor Carpi Radialis Brevis Tendon Injury, Prevention in Youth Sports (Early Sports Specialization): Injuries of the Throwing Shoulder. 2008;33(8):1380–3. Osteochondritis dissecans (OCD) of the humeral capitellum is a critical elbow injury in adolescent overhead throwing athletes. However, we are very careful with this treatment arm of the algorithm because the elbow loses functional range of motion faster than most joints in the body when it is immobilized. Osteochondritis dissecans (OCD) of the capitellum is an uncommon disorder seen primarily in the adolescent overhead athlete. The lesions can be treated by either conservative or operative methods with good to excellent results reported in most situations. This condition typically affects young athletes, such as throwers and gymnasts, involved in high-demand, repetitive overhead, or weightbearing activities. Stage II is marked by several spotted areas of higher intensity than cartilage. CASE HISTORY: This Patient is a 14 year old right hand dominant male … Each of these interventions has had variable short-term outcomes, and the ideal management strategy has yet to be determined. An axillary view of the bent elbow, taken in the style of a knee Merchant view, may also provide better visualization of the capitellum as well as the posteromedial aspect of the elbow, where loose bodies are often found ( ) ( Fig. Elbow involvement in osteochondritis dissecans is rare. The separated fragments are sometimes called “joint mice”. Radiographs are the most common initial modality for screening patients with suspected OCD. The involvement of the capitellum is more diffuse, with radiographs revealing loss of the normal contour of the capitellum ( ). Among male relatives of affected males, the prevalence rate is 14.6%. Osteochondritis dissecans of the capitellum is a well-recognized cause of elbow pain and disability in the adolescent athlete. 32.5 ). Hence, this compromise of the subchondral support structure promotes articular cartilage fragmentation and loose body formation ( ). In concert with traumatic insult, the vascular anatomy of the distal humerus underscores ischemia as a likely contributor to OCD of the capitellum. Mihara K, Tsutsui H, Nishinaka N, Yamaguchi K. Am J Sports Med. 2009 Feb;37(2):298-304. doi: 10.1177/0363546508324970. Repetitive stress to and compression of this tenuous blood supply may cause ischemia of the subchondral bone within the capitellum and the characteristic osteonecrosis observed in OCD. The etiology of this disorder is multifactorial and often cannot be determined. devised a more simplified classification, assigning lesions as stable or unstable. Modyfied wedge osteotomy for osteoarthritis of elbow secondary to osteochondritis dissecans in adolecent with multiple epiphyseal dysplasia. The introduction of elbow arthroscopy in the treatment of osteochondritis dissecans of the capitellum permits a thorough lesion assessment and evaluation of the entire elbow joint with the ability to treat the lesion and coexistent pathology in a minimally invasive fashion. Grade I Osteochondritis Dissecans in a Young Professional Athlete. Bexkens R, Oosterhoff JHF, Tsai TY, Doornberg JN, van den Bekerom MPJ, Eygendaal D, Oh LS. An arthroscopic classification was developed by and later modified by the International Cartilage Repair Society. Investigators have found high sensitivity (89% to 100%) of MRI for detecting unstable lesions when all four of the following Kijowski criteria are present: (1) a rim of high signal on T2-weighted images, (2) surrounding cysts, (3) a fluid-filled osteochondral defect, and (4) a thin high-intensity fracture line on T2-weighted images ( ). Typically it is seen in gymnasts or baseball players with repetitive compression to the outside of the elbow.  |  The exact etiology of OCD is not clear, but it is believed that repetitive trauma is the primary cause. Successful conservative treatment requires the reduction or elimination of all stress for a period of at least 6 weeks to allow the subchondral bone to stabilize, heal, and support the overlying cartilage. With this maneuver, passive forearm pronation and supination with the elbow in midrange flexion and extension during application of an axial load recreates pain at the radiocapitellar joint. The treatment of patients with capitellar osteochondritis dissecans is primarily determined by the stability of the osteochondritis dissecans lesion. Osteochondritis dissecans (OCD) of the outer elbow side of the arm bone, or capitellum, is a condition that results from repetitive trauma to the capitellum. Unlike Panner disease, a self-limiting condition of the immature capitellum, OCD is multifactorial and likely results from microtrauma in the setting of cartilage mismatch and vascular susceptibility. Takahara radiographic view of the elbow in a skeletally immature athlete. A localized injury and subsequent separation of articular cartilage and subchondral bone of the capitellum ; Epidemiology ... - Osteochondritis Dissecans of Elbow B 6/7/2020 262 . Osteochondritis dissecans in … Physical examination reveals tenderness over the radiocapitellar joint in the posterolateral elbow in some cases. It typically occurs in gymnasts and overhead throwers and presents along a wide spectrum of severity. Athletes with OCD of the capitellum often complain of diffuse, nonspecific pain with activity. Once the disease is diagnosed and defined by history, physical examination, and radiologic evaluation, the best treatment options can be discussed. With time, the overlying articular cartilage begins to break down and is increasingly vulnerable to shear stress because of inadequate subchondral osseous support, leading to separation, fragmentation, and loose body formation ( ). Must distinguish from Panner’s Disease, transient osteonecrosis of the capitellum which typically occurs at younger ages, 5-12yo. 2017 Aug 10;14(4):515-519. doi: 10.1016/j.jor.2017.08.011. This disorder is an idiopathic osteochondrosis of the entire immature capitellum. Osteochondritis dissecans (OCD) is a condition of articular cartilage and subchondral bone causing lateral elbow pain and stiffness in adolescent overhead athletes. Clin Sports Med. Grade II lesions are stable when probed but demonstrate partial discontinuity. It can be distinguished from the more benign Panner’s disease, as Panner’s is self-limiting, requires minimal … The elbow is positioned in approximately 45 degrees of flexion with the beam aimed perpendicular to the forearm. 4th ed. This site needs JavaScript to work properly. Deciding when healing has occurred to an extent great enough to start a slow and planned progression back into daily functioning and, ultimately, athletic activities is difficult. Treatment is based on lesion size and stability as well as the condition of the surrounding articular cartilage. Capitellar OCD is relatively uncommon but Late findings include the presence of loose bodies, degenerative changes, and radial head enlargement. As the natural history of the condition is one of progressive impairment and joint degeneration, efforts have been made to improve both non-operative and operative treatment. As the understanding of these lesions grows and better methods for diagnosing and treating them become known the ultimate effect of OCD may lessen to insignificance. proposed a classification scheme of capitellar OCD lesion stability based on T2-weighted MRI sequences. Clipboard, Search History, and several other advanced features are temporarily unavailable. Rest and antiinflammatory medications are typically effective in relieving the pain, features that may contribute to the delayed presentation that often occurs with this pathology. 32.4 ). Osteochondritis Dissecans of the Capitellum. The true cause, natural history, and optimal treatment of osteochondritis dissecans of the capitellum remain unknown. In later stages of the disorder there will be swelling of the affected joint which catches and locks during movement. OCD can mean one or more flakes of articular cartilage have become separated. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. This condition typically affects young athletes, such as throwers and gymnasts, involved in high-demand, repetitive overhead, or weightbearing activities. Finally, it also commonly occurs in persons who participate in racquet sports and in weight lifting. 32.3 ). 2017 Sep;26(9):1629-1635. doi: 10.1016/j.jse.2017.03.010. A plain anteroposterior radiograph with the elbow in 45° of flexion is … Genetic factors are thought to play a secondary role in the pathogenesis. Unfortunately, except for a few circumstances, there is no consensus at this point on an acceptable system. A grade IV lesion is either an empty defect, a defect with a dislocated fragment, or a loose fragment lying within the bed. Osteochondritis dissecans (OCD) of the capitellum is an injury that often afflicts young athletes, especially young gymnasts and baseball pitchers. Osteochondritis dissecans lesions of the capitellum in overhead athletes: a review of current evidence and proposed treatment algorithm. In early-stage lesions, the T1-weighted MR image demonstrates uniform low-intensity changes in the superficial capitellum, although the T2-weighted imaging findings remain normal. The stability of OCD lesions has a significant impact on prognosis and treatment and can be predicted on MRI in some cases. Many writers suggest that the timeline may be as long as 6 months to allow complete healing. Mourad F, Maselli F, Patuzzo A, Siracusa A, Di Filippo L, Dunning J, de Las Peñas CF. 1999 Nov-Dec;27(6):728-32. doi: 10.1177/03635465990270060701. Patients may also complain of accompanying elbow stiffness and loss of motion. Osteochondritis dissecans (OCD) of the capitellum is a localized disorder of the subchondral bone, in a region with limited healing capacity. Currently, the key to successful treatment is early detection. Osteochondritis dissecans (OCD or OD) is a joint disorder primarily of the subchondral bone in which cracks form in the articular cartilage and the underlying subchondral bone. Although radiographic findings are often negative in the early phases of the disease, the most classic finding is a focal radiolucency or irregularity in the anterolateral capitellum ( Fig. Osteochondritis dissecans (os-tee-o-kon-DRY-tis DIS-uh-kanz) is a joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). 2003 Feb;19(2):210-4. doi: 10.1053/jars.2003.50052. J Shoulder Elbow Surg. Grade II lesions possess a clear zone between the lesion and the adjacent subchondral bone. 4 . Yoshida T, Kim WC, Oka Y, Nakase M, Nishida A, Wada H, Arai Y, Kubo T. J Orthop. It may progress to become elbow osteoarthritis. Osteochondritis dissecans (OCD) of the capitellum is an uncommon disorder seen primarily in the adolescent overhead athlete. Osteochondritis dissecans of the capitellum is an uncommon cause of lateral elbow pain in adolescents and young adults. 2. From Crotin RL. For this reason, the senior author (CWN) often exercises athletes in the office (i.e., throwing baseballs) to provoke their symptoms. The dominant arm is more commonly involved, although bilateral involvement has been reported ( ). Overhead athletes place the medial elbow stabilizing complex under significant repetitive stress with consequent lateral elbow compression and shear forces. NLM Stable lesions are those that heal with rest and are characterized by an open capitellar growth plate, contained flattening or radiolucency of the subchondral bone, and decent range of motion. On ultrasound, loss of the smooth articular surface served as an excellent indicator of an OCD . Osteochondritis dissecans of the capitellum is a well-recognized cause of elbow pain and disability in the adolescent athlete. Stage III lesions show a discontinuous and noncircular capitellum chondral surface. This bone and cartilage can then break loose, causing pain and possibly hindering joint motion.Osteochondritis dissecans occurs most often in children and adolescents. Side view of a pitcher at the point of maximal shoulder and elbow stress. Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. The Research in Osteochondritis of the Knee (ROCK) study group has come to define OCD as “a focal, idiopathic alteration of subchondral bone with risk of instability and disruption of adjacent articular cartilage that may result in premature osteoarthritis” ( ). Osteochondritis dissecans (OCD) of the capitellum is a condition of the lateral elbow that often affects skeletally immature athletes, especially those who repeatedly subject the radiocapitellar joint to compressive forces. 0 . eCollection 2020 Nov. Logli AL, Bernard CD, O'Driscoll SW, Sanchez-Sotelo J, Morrey ME, Krych AJ, Camp CL. Elbow radiographs may be normal in the early stages of OCD of the capitellum. Epub 2008 Dec 4. JEFFREY GUTTMAN, M.D., Resident, Orthopaedic Surgery. Medical examinations using ultrasonography found that the prevalence of capitellar OCD among adolescent baseball players was approximately from 1% to 3%. Although radiography is a crucial initial imaging study, its sensitivity for detection of capitellar OCD is as low as 66% according to one study ( ). Arthroscopic treatment of osteochondritis dissecans of the capitellum: Report of 5 female athletes. Stage IV lesions are characterized by separation from the capitellum chondral surface by a high signal interface. MRI has proved useful for better characterizing OCD lesions and guiding treatment. A major disadvantage of ultrasound is the high variability in its accuracy, which is based on the skill and experience of the operator ( ). ORTHOPAEDIC DEPARTMENT . This condition typically affects young athletes, such as throwers and gymnasts, involved in high-demand, repetitive overhead, or weightbearing activities. 2019 Mar;12(1):1-12. doi: 10.1007/s12178-019-09528-8. Repetitive microtrauma in the susceptible elbow initiates fatigue fracture, resorption, and ultimately fragment separation from the underlying subchondral bone, as demonstrated by through rabbit models. Takahara M, Ogino T, Fukushima S, Tsuchida H, Kaneda K. Am J Sports Med. Computed tomography (CT) may be used to better define the osseous anatomy and subchondral bone, and CT arthrography can more accurately assess for loose bodies ( ). In the elbow, an OCD is localized most commonly at the humeral capitellum. Patients who present with OCD of the capitellum are typically athletes between ages 11 and 21 years ( ). The blood supply to the capitellum arises primarily from posterior perforating vessels that traverse the epiphyseal articular cartilage without metaphyseal collateral circulation ( ). Osteochondritis dissecans of the capitellum.  |  Supplemental views helpful for visualizing more of the capitellar surface include an AP image of the distal humerus with the beam angled 30 degrees cephalad, and an AP view with 45 degrees of elbow flexion, otherwise known as the Takahara view ( ) ( Fig. Philadelphia: WB Saunders; 2009. p. 288–96. Takeba, J, Takahashi, T, Hino, K, Watanabe, S, Imai, H, Yamamoto, H. Arthroscopic technique for fragment fixation using absorbable pins for osteochondritis dissecans of the humeral capitellum: a report of 4 cases. 2001 Jul;20(3):565-90. doi: 10.1016/s0278-5919(05)70270-2. Curr Rev Musculoskelet Med. eCollection 2017 Dec. Osteochondritis dissecans of the humeral capitellum. 32.6 ). doi: 10.1016/j.eats.2020.07.022. Use of repeated imaging, although intuitively a good idea, is not established as a viable method to determine the appropriate timing of return to activities. It usually occurs in baseball players, but can occasionally happen in other athletes that throw overhead. OCD of the humeral capitellum remains a difficult problem to treat. The natural history of OCD is poorly understood, and degenerative joint disease … Ultimately, repetitive stress of this nature leads to disruption of a localized portion of the subchondral bone and, if allowed to progress, the overlying articular cartilage. OCD usually causes pain during and after sports. Grade III lesions show complete discontinuity but have not dislocated. Ultimately the decision on how to treat a particular lesion is determined both by the extent of the lesion and by the athlete’s desire to participate in the chosen sport. devised the first classification scheme for capitellum OCD lesions based on AP radiographs: Grade I lesions demonstrate a stable lesion with a translucent cystic shadow in the lateral or middle capitellum. Knee Surg Sports Traumatol Arthrosc. Throwers, overhead athletes, and upper extremity weight bearing athletes (gymnasts) are at higher risk of capitellum OCD lesions. Once radiographic changes are obvious, long-term studies suggest that half of affected individuals will be symptomatic. Magnetic resonance imaging (MRI) is a valuable tool for assessing OCD of the capitellum and is more sensitive than radiographs. Osteochondritis dissecans (OCD) is a disorder of articular cartilage and subchondral bone. Osteochondritis dissecans of the elbow occurs in up to 3% of young athletes. This scheme has been well adopted because of its relative ease of use; however, it has not been shown to correlate well with treatment outcomes ( ). This point is defined as early acceleration with the shoulder near its point of maximal external rotation. However, once an athlete complains of clicking or locking, regardless of the timeliness of diagnosis and the patient’s age, the likelihood that conservative management will be successful decreases. Crepitus at the elbow may be palpable with flexion and extension. In the evaluation for suspected osteochondritis dissecans of the capitellum, standard elbow radiographs, including anteroposterior (AP), oblique radial head, and lateral views, should be obtained ( Fig. USA.gov. HHS This same phenomenon extends to OCD of the capitellum. 2018 Jul-Aug;52(4):344-352. doi: 10.4103/ortho.IJOrtho_322_17. If conservative treatment is not possible or fails, surgical options include open debridement with fragment excision, arthroscopic debridement and marrow stimulation, fragment fixation, closing wedge osteotomy of the distal humerus, osteochondral autograft, and osteochondral allograft. There is a lack of consensus on what MRI findings do or do not indicate instability; however, most writers believe that unstable OCD lesions can be identified on T2-weighted imaging from a fluid signal between the OCD and the underlying bone, as well as from a discrete round high–signal intensity area representing a cyst under the OCD lesion ( ) ( Fig. Capitellar osteochondritis dissecans (OCD) is one of the most common causes of elbow pain and dysfunction in adolescent athletes. Contained lesions seem to have better outcomes than uncontained lesions. Ultrasonography is another potential diagnostic imaging tool for capitellar OCD. In overhead athletes place the medial elbow Injuries in baseball players, but it is believed to affect 4.1 every..., Tsuchida H, Nishinaka N, Yamaguchi K. Am J Sports Med from the underlying. Other athletes that throw overhead analysis using quantitative 3-dimensional computed tomography and mapping technique in later stages, T1-weighted. 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