In concert with traumatic insult, the vascular anatomy of the distal humerus underscores ischemia as a likely contributor to OCD of the capitellum. Based on these imaging findings a diagnosis of osteochondritis dissecans (OCD) of the capitellum was made. Bexkens R, Oosterhoff JHF, Tsai TY, Doornberg JN, van den Bekerom MPJ, Eygendaal D, Oh LS. CrossRef PubMed Google Scholar. 22 Abstract Background: The goals of this study were to … eCollection 2020 Nov. Logli AL, Bernard CD, O'Driscoll SW, Sanchez-Sotelo J, Morrey ME, Krych AJ, Camp CL. 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. The presence of these OCD lesions is now better recognized, but their etiology is often not known and is certainly multifactorial in many instances. MRI has proved useful for better characterizing OCD lesions and guiding treatment. In book: Sports Injuries of the Elbow (pp.63-72) Authors: Christiaan J A van Bergen. It typically occurs in gymnasts and overhead throwers and presents along a wide spectrum of severity. 13. Osteochondritis dissecans of the capitellum is a well-recognized cause of elbow pain and disability in the adolescent athlete. CLINICAL CASE PRESENTATION . 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. 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. Osteochondritis dissecans (OCD) is a disorder of articular cartilage and subchondral bone. Must distinguish from Panner’s Disease, transient osteonecrosis of the capitellum which typically occurs at younger ages, 5-12yo. 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. 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. The most common early symptom of a capitellar OCD lesion is a gradual, progressive onset of lateral elbow pain. 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. Osteochondritis dissecans (OCD) of the capitellum is an uncommon disorder seen primarily in the adolescent overhead athlete. Osteochondritis Dissecans of the Elbow. Capitellar osteochondritis dissecans (OCD) is one of the most common causes of elbow pain and dysfunction in adolescent athletes. Crepitus at the elbow may be palpable with flexion and extension. This condition typically affects young athletes, such as throwers and gymnasts, involved in high-demand, repetitive overhead, or weightbearing activities. 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. Through a cadaveric ink-injection study of the skeletally mature elbow, determined that the main arterial contributors to the lateral elbow are the radial and middle collateral, radial recurrent, and interosseous recurrent arteries. 0 . Nonetheless the use of ultrasound as a simple and noninvasive tool has been advocated by several writers as a way to screen young, susceptible athletes for asymptomatic lesions as well as to access vascularity of the lesion ( ). 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 is an uncommon cause of lateral elbow pain in adolescents and young adults. Although radiography is a crucial initial imaging study, its sensitivity for detection of capitellar OCD is as low as 66% according to one study ( ). 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 ( ). Provoking compressive forces on the capitellum commonly occur in the dominant arm of overhead throwing athletes and from weight-bearing stress in gymnasts in the second decade of life. Osteochondritis dissecans of the capitellum in fraternal twins: case report. Physical examination reveals tenderness over the radiocapitellar joint in the posterolateral elbow in some cases. Arthroscopic treatment of osteochondritis dissecans of the capitellum: Report of 5 female athletes. Osteochondritis dissecans of the capitellum: lesion size and pattern analysis using quantitative 3-dimensional computed tomography and mapping technique. 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.  |  Once the disease is diagnosed and defined by history, physical examination, and radiologic evaluation, the best treatment options can be discussed. 2008;33(8):1380–3. 2019 Mar;12(1):1-12. doi: 10.1007/s12178-019-09528-8. Grade I Osteochondritis Dissecans in a Young Professional Athlete. 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. described a method to visualize the articular surface and subchondral bone by utilizing long-axis and short-axis views of the anterior and posterior capitellum. Grade II lesions are stable when probed but demonstrate partial discontinuity. Elbow radiographs may be normal in the early stages of OCD of the capitellum. Nonoperative management when OCD is diagnosed at an early stage can be successful and has been the mainstay of treatment in skeletally immature patients for many years. This disorder is an idiopathic osteochondrosis of the entire immature capitellum. This condition typically affects young athletes, such as throwers and gymnasts, involved in high-demand, repetitive overhead, or weightbearing activities. This condition typically affects young athletes, such as throwers and gymnasts, involved in high-demand, repetitive overhead, or weightbearing activities.  |  Osteochondritis dissecans (OCD) of the capitellum is an injury that often afflicts young athletes, especially young gymnasts and baseball pitchers. CRAIG MORGAN, M.D., Attending, Orthopaedic Surgery. 2017 Sep;26(9):1629-1635. doi: 10.1016/j.jse.2017.03.010. A major disadvantage of ultrasound is the high variability in its accuracy, which is based on the skill and experience of the operator ( ). For this reason, the senior author (CWN) often exercises athletes in the office (i.e., throwing baseballs) to provoke their symptoms. Osteochondritis dissecans of the capitellum is a well-recognized cause of elbow pain and disability in the adolescent athlete. HHS 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. Osteochondritis dissecans (OCD) is a condition of articular cartilage and subchondral bone causing lateral elbow pain and stiffness in adolescent overhead athletes. Athletes with OCD of the capitellum often complain of diffuse, nonspecific pain with activity.  |  OCD of the capitellum is more commonly found in male adolescent athletes engaging in repetitive overhead activities and has been associated with baseball, gymnastics, tennis, weight lifting, wrestling, and cheerleading. 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. The elbow and its disorders. The radiocapitellar compression test is a useful physical examination maneuver for diagnosis. Finally, it also commonly occurs in persons who participate in racquet sports and in weight lifting. Osteochondritis dissecans (OCD) of the humeral capitellum is a critical elbow injury in adolescent overhead throwing athletes. 32.4 ). Athletes rarely recall any specific trauma to the elbow. 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. WILMINGTON, DELAWARE . 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. Unfortunately, the ability to prognosticate when conservative treatment will be successful is not well established, and the decision whether to initiate nonoperative versus operative management in capitellar OCD focuses on the extent of disease, the time from onset of symptoms, and the patient’s expectations and desires. A collaborative approach to prevent medial elbow injuries in baseball pitchers. Elbow is flexed 110 to 120 degrees, and the shoulder is slightly externally rotated. Along the same lines, female gymnasts invoke a similar injury mechanism through repetitive loading of the radiocapitellar joint with their arms in extension ( ). Late findings include the presence of loose bodies, degenerative changes, and radial head enlargement. OCD can mean one or more flakes of articular cartilage have become separated. 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. In this system, grade I lesions are stable with continuous but softened areas of intact cartilage. 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). Magnetic resonance imaging (MRI) is a valuable tool for assessing OCD of the capitellum and is more sensitive than radiographs. 1999 Nov-Dec;27(6):728-32. doi: 10.1177/03635465990270060701. A grade IV lesion is either an empty defect, a defect with a dislocated fragment, or a loose fragment lying within the bed. Prompt recognition of this disorder and institution of nonoperative treatment for early, stable lesions can result in healing with later resumption of sporting activities. Osteochondritis dissecans also occurs in females, most notably gymnasts. Patients who present with OCD of the capitellum are typically athletes between ages 11 and 21 years ( ). 32.2 ). 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. For a general discussion of osteochondritis dissecans refer to the parent article - osteochondritis dissecans. 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. 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. Osteochondritis dissecans of the capitellum. Osteochondritis dissecans. The treatment of patients with capitellar osteochondritis dissecans is primarily determined by the stability of the osteochondritis dissecans lesion. Athletes often present to the physician’s office after a period of rest, lowering the diagnostic yield of physical examination. J Shoulder Elbow Surg. It may progress to become elbow osteoarthritis. Treatment is based on lesion size and stability as well as the condition of the surrounding articular cartilage. Osteochondritis dissecans of the elbow occurs in up to 3% of young athletes. The true cause, natural history, and optimal treatment of osteochondritis dissecans of the capitellum remain unknown. OCD lesions occur when an area of discrete articular surface begins to separate from the damaged underlying subchondral bone. Classic radiography finding of capitellar OCD with radiolucency of the anterolateral capitellum. It occurs in a younger age group (4–12 years) than capitellar OCD and is predominantly found in boys. Osteochondritis dissecans (OCD) is a musculoskeletal condition that occurs primarily during the maturation of the skeleton. Osteochondritis dissecans in … Modyfied wedge osteotomy for osteoarthritis of elbow secondary to osteochondritis dissecans in adolecent with multiple epiphyseal dysplasia. Shaughnessy WJ. Historically, surgical treatment included arthrotomy with loose body removal and curettage of the residual osteochondral defect base. 2003 Feb;19(2):210-4. doi: 10.1053/jars.2003.50052. On ultrasound, loss of the smooth articular surface served as an excellent indicator of an OCD . Throwers, overhead athletes, and upper extremity weight bearing athletes (gymnasts) are at higher risk of capitellum OCD lesions. These lesions, although often asymptomatic, can cause a significant interruption in a young athlete’s sports participation and in his or her day-to-day lives when the disease goes undiagnosed or is allowed to progress until significant symptoms occur. COVID-19 is an emerging, rapidly evolving situation. 32.5 ). 14. 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. Clin Sports Med. Axillary radiographic view of the elbow. Side view of a pitcher at the point of maximal shoulder and elbow stress. eCollection 2017 Dec. Osteochondritis dissecans of the humeral capitellum. With delayed presentation, patients may lack the terminal 15 to 30 degrees of elbow extension ( ). Curr Rev Musculoskelet Med. Osteochondritis dissecans is a joint condition in which a piece of cartilage, along with a thin layer of the bone separates from the end of the bone because of inadequate blood supply. The elbow is positioned in approximately 45 degrees of flexion with the beam aimed perpendicular to the forearm. The lesions can be treated by either conservative or operative methods with good to excellent results reported in most situations. However, its etiology remains unknown. Unlike OCD, Panner’s disease is a self-limiting process that normally resolves completely with activity modification and rest ( ). Panner’s disease must be considered in the differential diagnosis of a young athlete with elbow pain. Philadelphia: WB Saunders; 2009. p. 288–96. Humeral capitellum osteochondritis dissecans is believed to affect 4.1 of every 1000 males. Int J Sports Phys Ther. 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. 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” ( ). 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. Despite the uncertainty of its etiology, symptomatic OCD of the capitellum arises primarily from repetitive stress to the elbow ( ). Capitellar OCD is relatively uncommon but Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. 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. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Osteochondritis dissecans lesions of the capitellum in overhead athletes: a review of current evidence and proposed treatment algorithm. A disadvantage to consider with CT is the radiation exposure imparted on the young athlete. OSTEOCHONDRITIS DISSECANS OF THE CAPITELLUM . NLM Nonoperative treatment for osteochondritis dissecans of the capitellum. In the elbow, an OCD is localized most commonly at the humeral capitellum. Yoshida T, Kim WC, Oka Y, Nakase M, Nishida A, Wada H, Arai Y, Kubo T. J Orthop. devised a more simplified classification, assigning lesions as stable or unstable. doi: 10.1016/j.eats.2020.07.022. It is defined as a localized fragmentation of bone overlying the capitellum cartilage. JEFFREY GUTTMAN, M.D., Resident, Orthopaedic Surgery. The pathophysiology of OCD resembles that of mechanical trauma to articular cartilage. On the contrary, unstable lesions possess one of the following characteristics: a closed capitellar growth plate, lesion fragmentation, or restricted elbow motion ≥ 20 degrees. Arthroscopy. 1. repetitive throwing / valgus stress and gymnastics / weight bearing on upper extremity 1.1. valgus stress / compressive force on the vulnerable chondroepiphysis of the radiocapitellar joint in skeletally immature patients is supported as the etiology for OCD of the capitellum 8 2. ankle sprain/instability 2.1. In the talus, 96% of lateral lesions and 62% of … 32.3 ). This same phenomenon extends to OCD of the capitellum. Patients with unstable lesions or those failing nonoperative therapy require operative intervention with treatment based on lesion size and extent. The elbow should be examined for any evidence of effusion. 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 in the treatment of knee OCD lesions, results of nonoperative treatment are better in younger, prepubescent athletes with wide open physes ( ). J Hand Surg Am. Osteochondritis dissecans (OCD) of the capitellum is an uncommon disorder seen primarily in the adolescent overhead athlete. Diagnosis and treatment. June 4, 1996. January 2021; DOI: 10.1007/978-3-030-52379-4_6. In: Morrey BF, Sanchez-Sotelo J, editors. 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. The dominant arm is more commonly involved, although bilateral involvement has been reported ( ). Knee Surg Sports Traumatol Arthrosc. Osteochondritis Dissecans OCD of the capitellum is character-ized by noninflammatory degenera-tion of subchondral bone occurring in the context of repetitive loading to the lateralcompartmentoftheelbow.Pan-ner disease and OCD may represent two different stages of the same disor-der, but they differ in the patient’s age Gardiner TB. 2020 Nov 20;9(11):e1727-e1730. In later stages of the disorder there will be swelling of the affected joint which catches and locks during movement. Onset is between childhood and middle age, with the majority of patients being between 10 and 40 years of age, with approximately a 2:1 male to female ratio 3. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. 32.6 ). It usually occurs in baseball players, but can occasionally happen in other athletes that throw overhead. Suspicion of … 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. Clin Sports Med. Osteochondritis dissecans (OCD) of the humeral capitellum is a sports-related disorder in young athletes, especially baseball players and gymnasts. 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. In the elbow, the most common area affected is the capitellum, although it has been reported to affect the olecranon and the trochlea. OCD usually causes pain during and after sports. Patients may also complain of accompanying elbow stiffness and loss of motion. Osteochondritis Dissecans of the Capitellum. Grade III lesions show complete discontinuity but have not dislocated. 2001 Jul;20(3):565-90. doi: 10.1016/s0278-5919(05)70270-2. Epub 2008 Dec 4. Hence, this compromise of the subchondral support structure promotes articular cartilage fragmentation and loose body formation ( ). Elbow pain seen in the at-risk athlete, such as a baseball player (in particular, a pitcher) or gymnast, should raise suspicion for OCD. Although many theories have been proposed, such as ischemia, genetic factors, and microtrauma, the etiology of OCD remains unclear. 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 . 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 ( ). Osteochondritis dissecans (OCD) of the humeral capitellum is a disorder affecting mainly boys between the ages of 12 and 15 years. Furthermore, patients’ lesions often heal their and patients return to full activities despite the lack of full radiographic healing. USA.gov. Seen primarily in young overhead athletes such as baseball players, the condition is thought to be secondary to repetitive compressive and shearing forces that are exerted by the radial head on the humeral capitellum during the throwing motion. Shoulder and elbow stress occurs primarily during the maturation of the subchondral support structure promotes articular cartilage its,... Occurs at younger ages, 5-12yo Nishinaka N, Yamaguchi K. Am J Sports.! 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