Capitellar OCD

Epidemiology

 

Adolescents & young adults

 

Usually between 12 - 21 years 

 

Throwing athletes / gymnasts

 

Little Leaguer's Elbow

- combination of capitellar OCD and MCL injury

- a repetitive throwing injury / seen in pitchers

 

Aetiology

 

1.  Trauma & Overuse

 

Common throwing sports / gymnastics

- dominant limb predominates

- repetitive overuse

- valgus overload on radiocapitellar joint 

- fatigue failure of the subchondral area 

- overlying cartilage fails under shear stress & separates

 

Capitellum loaded more heavily

- less able to take load than radial head articular surface

- especially if have some slight eccentric loading which can occur in throwing athlete or gymnast

 

2.  Ischaemia

 

Predominant blood supply to capitellum from posterior vessels

- histopathology shows osteonecrosis

 

Pappas Classification   

 

Category 1  - patients < 13 years of age 

Category 2  - 13 years to adulthood 

Category 3  - adults 

 

Found better prognosis with younger patients 

- especially with open capitellar growth plate

- respond better to non operative treatment

 

Symptoms

 

Dominant arm / history of over-use

 

Pain activity related

 

Limited range

- very common presentation

 

Clicking, grinding, catching, locking

- ? Loose bodies

 

Examination

 

Tender over lateral aspect elbow

 

Loss of extension

 

Radio-capitellar compression test

- active supination and pronation with arm fully extended

 

Examine MCL

 

Iwase's Classification Xray

 

Grade 1

- localised flattening and translucency

 

Capitellar OCDElbow OCD

 

Grade 2

 

A:  Small fragment without sclerosis

B:  Small fragment with sclerosis

 

Elbow OCD Type 2BElbow OCD Type 2B CT

 

Grade 3

- in situ loose body

 

DDx

 

Panner's disease / osteochondrosis

- child 4 - 8 years old

- entire capitellum involved

- not sure if is earlier spectrum of same disease

 

MRI

 

Fluid interface denotes detachment / instability

 

Capitellar OCD MRI

 

Management

 

Non Operative

 

Indications

 

Stable lesion

- intact cartilage

- nil detachment / no synovial fluid behind OCD

 

Option

 

Protected ROM

- hinged brace

- attempt to reduce axial load

- nil sports until full ROM

- 3-6 months

 

Results

 

Mihara et al Am J Sports Med 2009

- 39 baseball players mean age 13 years

- cessation of throwing, weights, push ups

- healing of lesion in 16/17 patients with open growth plates

- healing of lesion in 11/22 with closed growth plates

- 25/30 early stage lesions healed

- only 1/9 advanced stage lesions healed (Grade 2A and Grade 3)

- suggest early surgical intervention in advanced OCD

- recommend surgical intervention if no sign of healingin 3-6 months

 

Operative

 

Indications

 

1.  Failure non operative treatment

2.  Loose bodies

3.  Instability / displacement

 

Large / salvageable fragments

 

A.  Stable / Drill in situ

 

Elbow OCD InsituElbow OCD Retrograde Drilling

 

Arthroscopic technique

- anterograge via anterolateral portal if possible

- retrograde via ACL jig / posterolateral portal with elbow flexed

 

B.  Unstable / Fixation

 

Arthroscopic technique

- via soft spot portal

 

Takahara et al JBJS Am 2007

- demonstrated fragment fixation or reconstruction better than removal

- fragment fixation with bone graft

 

Small / unsalvageable Fragments

 

A. Arthroscopic Debridement

 

Elbow Scope Capitellar OCDElbow Scope OCD Debridement

 

Schoch et al Arthroscopy 2010

- arthroscopic debridement in 13 patients

- follow up average 3 years

- symptomatic relief

- 6/13 had to cease some sport

 

B.  Microfracture

 

Elbow Scope OCDElbow scope OCD Microfracture

 

C.  Abrasion

 

Elbow OCDElbow OCD Abrasion

 

Large Chondral Defects

 

A.  Mosaicplasty

 

Ovesen et al J Should Elbow Surg 2011

- 10 patients treated with mosaicplasty

- average age 21

- incorporation in all patients

- significant improvement in Mayo elbow scores

 

B.  MACI