Capitellar Osteochondritis Dissecans and Radiocapitellar Plica

16 Elbow Arthroscopy: Capitellar Osteochondritis Dissecans and Radiocapitellar Plica Christopher S. Ahmad, MD Mark A. Vitale, MD, MPH Neil S. ElAttrache, MD The radiocapitellar compartment of Abstract The combination of excessive radiocapitellar compressive forces and the limited the athlete’s elbow is subject to signifi- vascularity of the capitellum are responsible for the development of osteochondritis cant stresses during repetitive activi- dissecans. Repetitive compressive forces are generated by throwing or racket swing- ties, such as throwing, or upper ex- tremity weight-bearing sports, such as ing motions or from constant axial compressive loads on the elbow, which are com- 1 mon in athletes such as gymnasts. Symptoms include activity-associated pain and gymnastics. Radiocapitellar compres- stiffness. Physical examination findings show tenderness over the radiocapitellar sion can lead to Panner disease in pre- joint and, commonly, loss of extension. Plain radiographs may show flattening and adolescent children or capitellar osteo- sclerosis of the capitellum, lucencies, and possibly intra-articular loose bodies. MRI chondritis dissecans (OCD) in can detect bone edema early in the disease process and further delineate the extent adolescents or young adults; it is im- of the injury. The management of osteochondritis dissecans lesions is primarily portant to differentiate these two dis- orders because they have different nat- based on the demands of the patient, the size and location of the lesion, and the 2-5 status and stability of the overlying cartilage. Possible treatments include transar- ural histories and treatments. Elbow ticular drilling; removing detached fragments or loose bodies, followed by drilling; arthroscopic techniques can be used to and mosaicplasty. treat the OCD lesion with débride- Radiocapitellar plica can cause chondromalacic changes on the radial head and ment, drilling, and even mosaicplasty capitellum, with symptoms including painful clicking and effusions. Arthroscopic and can be used to treat loose bodies plica resection is indicated when nonsurgical treatment fails. that develop secondary to the OCD lesion. Instr Course Lect 2011;60:181-190. Panner Disease Panner disease predominantly affects boys younger than 10 years.6 Patients initially present for treatment with re- Dr. Ahmad or an immediate family member has received research or institutional support from Acumed, Ar- ports of activity-related pain and stiff- threx, and Zimmer. Dr. ElAttrache or an immediate family member serves as a board member, owner, officer, or committee member of the American Board of Orthopaedic Surgery and the American Orthopaedic Society for ness in the elbow. Tenderness over the Sports Medicine; has received royalties from Arthrex; is a member of a speakers’ bureau or has made paid presen- lateral elbow and the capitellum is tations on behalf of Arthrex; serves as a paid consultant to or is an employee of Acumed and Arthrex; serves as an found on physical examination. Ra- unpaid consultant to Arthrex; has received research or institutional support from Arthrex; and has received non- income support (such as equipment or services), commercially derived honoraria, or other non–research-related diographs initially show fissuring, lu- funding (such as paid travel) from Acumed and Arthrex. Neither Dr. Vitale nor any immediate family member cencies, fragmentation, and irregular- has received anything of value from or owns stock in a commercial company or institution related directly or in- directly to the subject of this chapter. ity of the capitellum. Subsequent © 2011 AAOS Instructional Course Lectures, Volume 60 181 Elbow the elbow during throwing or racket swinging or from constant axial compressive loads on the elbow, such as those experienced by gymnasts.7,10,11 The capitellum is supplied by two end arteries coursing from posterior to an- terior, which are branches of the radial recurrent and interosseous recurrent arteries.12 Local blood flow to the capitellum may be disrupted by both repetitive microtrauma or a single traumatic event leading to subchondral bone injury.13,14 Presentation Patients with OCD will initially pres- Figure 2 MRI scan showing capi- ent reporting activity-related pain and tellar OCD lesion (white arrow) with stiffness in the elbow. Mechanical and associated loose body (black Figure 1 AP radiograph showing arrow). (Adapted with permission symptoms of locking or catching, an OCD lesion (arrows) in the capi- from Ahmad CS, ElAttrache NS: caused by intra-articular loose bodies, tellum of the elbow. (Reproduced Treatment of capitellar osteochondri- may be present. The physical examina- with permission from Ahmad CS, tis dissecans. Tech Shoulder Elbow tion shows tenderness over the radio- ElAttrache NS: Treatment of capitel- Surg 2006;7:169-174.) capitellar joint. Loss of range of mo- lar osteochondritis dissecans. Tech Shoulder Elbow Surg 2006;7: tion with a 15° to 20° flexion 169-174.) contracture is common. The active ra- Osteochondritis Dissecans diocapitellar compression test suggests OCD of the capitellum is character- an OCD lesion when pain is elicited in radiographs show larger radiolucent ized by noninflammatory degenera- the lateral compartment of the elbow areas followed by reossification, with a tion of subchondral bone occurring in and when the patient pronates and su- corresponding resolution of symp- the context of repetitive loading to the pinates the forearm with the arm in ex- toms. One to 2 years after the initial lateral compartment of the elbow. Pan- tension. presentation, the epiphysis regains its ner disease and OCD may represent 4 normal contour and appearance. two different stages of the same disor- Imaging MRI scans typically show edema local- der, but they differ in the patient’s age Full-extension AP, 45°-flexion AP, and ized to the chondral surface, with less at onset and natural history.4 Panner lateral radiographic views of the elbow involvement of the subchondral bone disease affects children younger than should be obtained; however, results in comparison with OCD. 10 years, whereas OCD commonly af- may be negative early in the disease Treatment involves ceasing the ac- fects older athletes.7 OCD is not al- process (Figure 1). As the condition tivities causing elbow stress, and the ways self-limiting; if untreated it may progresses, flattening and sclerosis of use of ice and anti-inflammatory med- result in profound destruction of the the capitellum, typically on its antero- ication. For severe symptoms, the el- capitellum.7 lateral aspect, will become apparent. bow may be immobilized for 3 to Irregular areas of lucency and intra- 4 weeks. In general, symptoms usually Etiology articular loose bodies may be seen. It resolve within 6 to 8 weeks, although The combination of abnormal radio- should be noted if the capitellar physis they occasionally persist for months. capitellar compressive forces and the is open or closed. In patients with sus- Activities are resumed as tolerated. limited vascularity of the capitellum sup- pected OCD, an MRI scan of the el- Panner disease has an excellent long- plied by end arteries are likely responsi- bow should always be obtained (Fig- term prognosis, although some pa- ble for the development of OCD.2,5,8,9 ure 2). MRI can detect bone edema tients may experience loss of mo- Repetitive compressive forces are gen- early in the disease process.15 A mag- tion.4,6 erated by either large valgus stresses on netic resonance arthrogram can further 182 © 2011 AAOS Instructional Course Lectures, Volume 60 Elbow Arthroscopy: Capitellar Osteochondritis Dissecans and Radiocapitellar Plica Chapter 16 Table 1 Classification and Treatment of Capitellar Osteochondritis Dissecans Lesions Stability Stage Radiographic Findings Arthroscopic Findings Treatment Stable lesion I Normal radiographs Intact articular cartilage Hinged elbow brace T1-weighted MRI: abnormal Subchondral bone edema but Physical therapy T2-weighted MRI: normal structurally sound Nonsteroidal anti-inﬂammatory drugs Follow-up radiograph and/or MRI at 3 to 6 months Unstable II Abnormal radiographs Partially detached fragment Acute: Consider fragment ﬁxa- lesion T1- and T2-weighted MRIs: Cartilage fracture tion but higher success using abnormal Subchondral bone collapse treatment for chronic Contrast shows margin around Lateral buttress involved; Chronic: the lesion poorer prognosis (a) < 6 to 7 mm lateral buttress involved/radial head does not engage: fragment removal plus microfracture drilling (b) > 6 to 7 mm lateral buttress involved/head engages: removal plus osteochondral allograft/synthetic graft III Loose bodies Completely detached loose Loose body removal bodies Treat as stage II lesion Associated radial head Any of the above < 30% radial head involvement: deformity treat as stage II lesion > 30% radial head involvement: no osteochondral grafting; microfracture/drilling are OK (Reproduced with permission from Ahmad CS, ElAttrache NS: Treatment of capitellar osteochondritis dissecans. Tech Shoulder Elbow Surg 2006;7: 169-174.) delineate the extent of the injury be- Stage I pitchers may have to change throwing cause the contrast agent can reveal sep- In stage I lesions, the osteochondral positions, and gymnasts may need to aration of a detached or partially de- fragment is intact, stable, and nondis- elect a different sport. tached fragment from the subchondral placed. Radiographic findings are of- bone. ten negative. The signal findings on Stage II MRI are

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