OSTEOCHONDRITIS DISSECANS OF THE CAPITELLUM
JEFFREY GUTTMAN, M.D., Resident, Orthopaedic Surgery
CRAIG MORGAN, M.D., Attending, Orthopaedic Surgery
June 4, 1996
CLINICAL CASE PRESENTATION
THE ALFRED I. DUPONT INSTITUTE
This Patient is a 14 year old right hand dominant male who complains
of right elbow pain, swelling, and decreased ROM which has occurred intermittently
over the past year. He also describes clicking and "catching"
of the elbow. He claims that the pain has been getting progressively worse
and that it is worst after throwing when he plays dodgeball. On physical
examination, the patient has a minimal joint effusion and is tender over
his radiocapitellar joint line. He also lacks 15 degrees of terminal elbow
extension, but has full flexion. There is some crepitus with ROM. Plain
X-rays of the elbow show focal islands of subchondral bone adjacent to
the articular surface of the capitellum demarcated by a rarefied area.
The patient was scheduled for an elbow arthroscopy and possible drilling
of the lesion vs. debridement and removal of loose bodies. During the arthroscopy
the lesion was noted to be almost completely detached. It was debrided
and excised. No drilling was performed.
- Focal lesion of capitellum
- One of numerous entities under term "Little League elbow"
(medial epicondyle avulsion, delayed or accelerated growth medial epicondyle,
medial epicondyle apophysitis, delayed closure med. epicondyle growth plate,
osteochondrosis or OCD capitellum, deformity of radial head, olecranon
- Throwing athletes - baseball pitcher, tennis (serve), football (pass),
javelin thrower, gymnast
- Not as common as medial elbow injury
- One of leading causes of permanent elbow disability in young throwing
- Panner (1927) - first described lesion in capitellum similar to Perthes
disease of hip
(different etiology, onset, prognosis than OCD)
- Brogdon & Crow (1960) - "Little League elbow;" described
assoc. b/w pitching and medial epicondylar injuries
- Adams (1965) - lateral elbow joint damage secondary to pitching (6
cases of OCD of capitellum)
- Trauma/excessive use - well documented secondary to repetitive stress
to elbow of pitching; almost always dominant elbow
- Vascular anatomy - may make capitellum more vulnerable to trauma
- Genetic factors - high incidence of bilateral disease; common occurrence
among relatives of affected patients
- Elbow stabilizers :
- medial - MCL
- lateral - bony articulation of radial head/capitellum
- posterior - olecranon/olecranon fossa articulation
- These structures resist valgus forces of throwing and can be injured
- Valgus stress is the major pathologic mechanism of elbow (causes medial
tension and lateral compression)
- Compression overload of lateral articular surface - radial head abuts
- occurs mainly during early and late cocking phases
- also during follow through with rapid, maximal pronation
HISTORY AND PHYSICAL:
- Age 13 - 16. Usually male.
- Throwing athlete
- Insidious onset elbow pain; worse after throwing
- Dominant arm
- Decreased ROM (particularly extension)
- Crepitus, grinding
- Later c/o locking, catching with severe pain
- Plain XRays
- focal island of subchondral bone adjacent to articular surface of capitellum
demarcated by rarefied zone
- radiolucent, cystic-like area
- irregular ossification of capitellum
- radial head changes (irregularity, hypertrophy)
- loose bodies
- Initial XRay may be negative
- Tomogram may help determine whether articular surface and subchondral
bone are dissected from capitellum
- Type I : Intact lesion; no evidence of fracture of articular surface
- Type II : Partial detachment of lesion
- Type III : Completely detached loose body
- For Type I lesions can try rest, NSAIDs, avoiding all throwing activities
- If severe pain, splint 3-4 wks. Then begin active ROM
- Protect elbow until see radiographic evidence of revascularization
- Indications : if conservative treatment fails to relieve pain or gain
elbow extension; locked elbow; more aggressive approach: any painful OCD
(including Type 1)
- Removal loose bodies
- Internal fixation loose fragments, bone grafting poor results
- Often marks end of hard painless throwing
- Usually cannot return to pitching
- Promising results with arthroscopy/drilling Type I lesions
- Symptoms improvement with debridement, removal loose bodies
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Instr. Course Lect. 34: 323-331, 1985.
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3. Brown, R., et al. Osteochondritis of the Capitellum. J of Sports
Med, Vol. 2, No. 1: 27-46, 1974.
4. Jackson, D., et al. Osteochondritis in the Female Gymnasts Elbow.
Arthroscopy 5(2): 129-136, 1989.
5 . McManama, G., et al. The Surgical Treatment of Osteochondritis of
the Capitellum. Am J Sports Med 13(l): 11-21, 1985.
6. Pappas, A. Elbow Problems Associated with Baseball during Childhood
and Adolescence. CORR 164:30-41, 1982.
7. Smith, M. Osteochondritis of the Humeral Capitellum. JBJS 46B, No.
1: 50-54, 1964.
8. Waugh, T., et al. Surgical Management of Osteochondritis Dissecans
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