Osteochondritis Dissecans of the Elbow: Difference between revisions

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<div class="editorbox">'''Original Editor '''- [[User:Pamela Gonzalez|Pamela Gonzalez]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp; </div>  
<div class="editorbox">'''Original Editor '''- [[User:Pamela Gonzalez|Pamela Gonzalez]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp; </div>
== Search Strategy&nbsp;  ==


Searched databases&nbsp;: PubMed, PEDRo, Web of Science, Cochrane<br>Search terms&nbsp;: Osteochondritis Dissecans elbow, Osteochondrosis, elbow injury, Osteochondritis physical therapy, Osteochondritis diagnose, Osteochondritis Dissecans capitellum, osteochondritis dissecans elbow physical therapy, osteochondrosis&nbsp;


== Definition/Description&nbsp;  ==
== Definition/Description&nbsp;  ==


An increasingly recognised cause of elbow pain that affects subchondral bone and the overlying cartilage is called Osteochondritis Dissecans (OCD) of the elbow, also known as osteochondrosis of the elbow.<br>OCD can lead to subsequent degenerative arthritis or [http://www.physio-pedia.com/Osteoarthritis osteoarthritis.]<ref name="Steven">Steven A. Giuseffi et al. Osteochondritis dissecans of the elbow. Oper Tech Sport Med 2014; 22; 148-155 (Level of Evidence: 3A)</ref> Osteochondritis dissecans leads to fragmentation and separation of cartilage and underlying bone.<ref name="Champ">Champ L. Baker III et al. Osteochondritis dissecans of the capitellum. American Journal Of Sports Med; 38; 1917-1928 (Level of Evidence: 3A)</ref><br>Osteochondritis Dissecans (OCD) is defined as an inflammatory pathology of bone and cartilage resulting in localised necrosis and fragmentation of bone and cartilage. In the elbow, the most common area affected is the capitellum, although it has been reported in the olecranon and the trochlea.<ref name="Felix">Felix H. Savoie, III, MD; Oper Tech Sports Med 16:187-193 © 2008 Elsevier Inc (Level of Evidence: 2A)</ref> OCD summarised means that there are one or more flakes of articular cartilage that become separated. They will form loose bodies within the joint. The separated flakes stay alive (they are nourished by the synovial fluid) and the flakes often ossify.<ref name="Currey">H.L.F. Currey, Essentials of rheumatology, 1988,p166 (Level of Evidence: 5)</ref><br> [[Image:COCD.jpg|300px]]The cartilage is damaged and can form a loose body<ref name="Moon et al.">Young Lae Moon; Little league elbow; osteochondritis dissecans, 2012 (Level of Evidence : 5)</ref> [[Image:Foto met pijl.jpg]] On the anteroposterior digital radiograph you can see a faint, mobile, irregular, calcific opacity over the distal capitellum.<ref name="Currey" /><ref name="Folio et al.">Les Roger Folio et al., Loose Body in Elbow of a Baseball Player: Arthroscopic/Radiologic Correlation, Radiology case reports, 2006 (Level of Evidence : 3B)</ref>  
<br>Osteochondritis Dissecans (OCD) is defined as an inflammatory pathology of bone and cartilage. This can result in localized necrosis and fragmentation of bone and cartilage. [[File:Foto_met_pijl.jpg|Arrow points to calcific flake in distal capitellum<ref>Folio LR, Craig SH, Wright GA, Battaglia MJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4891554/ Loose body in elbow of a baseball player: arthroscopic/radiologic correlation.] Radiology case reports. 2006 Jan 1;1(2):62-5.</ref>|alt=|frame]]OCD of the elbow is most commonly seen in the sporting adolescent population (ages 12-14) in particular throwing sports or upper limb dominant sports such as baseball or hockey.<ref name="Steven">Giuseffi SA, Field LD. [https://www.infona.pl/resource/bwmeta1.element.elsevier-7be53c34-e265-3e4e-a836-42d279492d12 Osteochondritis dissecans of the elbow.] Operative Techniques in Sports Medicine. 2014 Jun 1;22(2):148-55.</ref><ref name="Felix" /> Hence the common term "Little league elbow".<ref name=":0">Klingele KE, Kocher MS. [https://www.ncbi.nlm.nih.gov/pubmed/12457420 Little league elbow.] Sports Medicine. 2002 Dec 1;32(15):1005-15.</ref>


In the [[elbow]], the most common area affected is the capitellum, although it has been reported to affect the olecranon and the trochlea.<ref name="Champ">Baker III CL, Romeo AA, Baker Jr CL. [http://journals.sagepub.com/doi/abs/10.1177/0363546509354969 Osteochondritis dissecans of the capitellum.] The American journal of sports medicine. 2010 Sep;38(9):1917-28.</ref><ref name="Felix">Felix H. Savoie, III, MD. [http://www.hkmacme.org/course/2009bw11-03-00/om%20cs_nov.pdf Osteochondritis Dissecans of the Elbow]. Operative Techniques in Sports Medicine.  2008 16:187-193</ref> OCD can mean one or more flakes of articular cartilage have become separated. Which form loose bodies within the joint. The separated flakes can then ossify due to nourishment by the synovial fluid.<ref name="Currey">Curry H. Essentials of Rheumatology. 1st ed. Churchill Livingstone; 1988. </ref> The cartilage is damaged and can form a loose body.<ref name="Moon et al.">Matsuura T, Suzue N, Iwame T, Nishio S, Sairyo K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555579/ Prevalence of osteochondritis dissecans of the capitellum in young baseball players: results based on ultrasonographic findings]. Orthopaedic journal of sports medicine. 2014 Aug 11;2(8):2325967114545298.</ref>
<br>In the long term OCD can lead to subsequent degenerative arthritis or [http://www.physio-pedia.com/Osteoarthritis osteoarthritis.]<ref name="Steven" />
== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


Involved anatomy of this disorder includes the radial head or the central and/or lateral aspect of the capitellum. Most OCD lesions of the elbow involve the capitellum, typically the central or lateral portion, but also the radial head, the olecranon of the ulnae and the trochlea humeri.<ref name="Steven" /><br>Also increased activity, loss of motion, and swelling on the lateral side of the elbow comes with increased pain.<ref name="Steven" /><br>
Involved anatomy of this disorder includes the [[Elbow|radial head]] or the central and/or lateral aspect of the [[Elbow|capitellum]].  


<br>  
Most OCD lesions of the elbow involve the capitellum, typically the central or lateral portion, but also the radial head, the olecranon of the ulna and the trochlea humeri.<ref name="Steven" />
== Epidemiology / Aetiology  ==


== Epidemiology / Ethiology  ==
Ostechondritis of the humeral capitellum is secondary to repetitive compression forces between radial head and capitellum.


<br>Ostechondrosis of the humeral capitellum is secondary to repetitive compressive forces between radial head and capitellum. This injury results in a loose body containing an osteochondral bone fragment that is detached from the articular surface. Causes of this pathology include injury or stress on the joint, lack of blood supply, and/or genetic makeup. <br>Repetitive high stress forces on the joint can result in a series of minor injuries on the elbow that can eventually lead to a fracture and ultimately detachment of the bony fragment from the bone.<br>Blockage of a small artery can also be a factor in this pathology. [http://www.physio-pedia.com/Avascular_Necrosis Avascular Necrosis] that leads to the lack of blood supply contributes to break down or death of bone tissue. Osteochondritis dissecans also has a genetic component allowing a predisposition to the pathology.<br> <br> Staging of osteochondritis dissecans is depicted below:<br> Staging of Osteochondritis Dissecans<ref>Champ L. Baker III et al. Osteochondritis dissecans of the capitellum. American Journal Of Sports Med; 38; 1917-1928 (Level of Evidence: 3A)</ref>  
Repetitive high stress forces on the joint can result in a series of minor injuries on the elbow that can eventually lead to bony fragmentation and ultimately detachment of the bony fragment from the bone.<ref name="Felix" />


Many factors are associated with the aetiology and development of avascular necrosis. They include the following components: genetics, anatomy, trauma, vascular, metabolic, haematogenous, endocrine, nutritional and inflammatory disorders.<ref>D Bain G, Pederzini L, Poehling G. Osteochondritis dissecans of the elbow: state of the art. Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine. 2017 Jan 1;2(1):47-57.


</ref>


Stage Appearance on MRI Stability of Lesion<br>  
Commonly seen in the adolescent sporting population; who partake in repetitive throwing or overhead activities such as baseball and gymnastics.<ref name="Moon et al." /> More frequently seen in males (ages 10-14) than females and often affecting the dominant arm.<ref name="Felix" /><ref name="Moon et al." /> <br> <br>


I Thickening of cartilage and a stable lesion<br> low signal changes
=== Stages of osteochondritis dissecans:<ref name="Champ" /> ===


II Articular cartilage interrupted and a stable lesion<br> low signal rim behind fragment <br> showing that there is fibrous <br> attachment
==== Stage I ====
Thickening of cartilage and a stable lesion  


III Articular cartilage interuppted, Unstable<br> high signal changes behind <br> fragment and underlying <br> subchondral bone
==== Stage II ====
Articular cartilage interrupted and a stable lesion low signal rim behind fragment showing that there is fibrous attachment


IV Loose body Unstable  
==== Stage III ====
Articular cartilage interrupted, Unstable high signal changes behind  fragment and underlying subchondral bone


[[Image:Staging OCD.jpg|350x200px]]<br> <br> This figure shows the different stages of Osteochondritis Dissecans. These vary from stage I to IV as explained above this picture. From left to right we can examine stage I through stage IV. <ref name="Seattle">Seattle children’s hospital; 1995-2015 (Level of Evidence : 5)</ref>
==== Stage IV ====
Loose body Unstable 


<br> Steven A. Giuseffi et al. believe the trigger is likely multifactorial. A couple of mechanisms that contribute to the development of OCD are: trauma, ischemia, disordered ossification and genetic abnormalities. But these mechanisms are momentarily not universally accepted but may be a contributing factor.<br>From another point of view vascular hypoperfusion and repeated microtrauma may also contribute to the development of OCD. Capillary blood supply is often limited to 1 or 2 end vessels with limited collateral flow. This leads to vascular hypoperfusion. Repeated microtrauma could lead to a production of a relatively avascular state in the vulnerable immature capitellar chondroepiphysis (Level of Evidence: 3A).<ref name="Steven" /><br> <br>  
{{#ev:youtube|v=1rPRxYGp08w&t=2s}}<ref>Frank Holowka. Osteochondritis Dissecans presentation. Available from: https://www.youtube.com/watch?v=1rPRxYGp08w&t=2s [last accessed: 11/03/14]</ref>  


The cause of OCD is likely multi-factorial. Causes of this pathology normally include injury or repetitive stress on the joint, lack of blood supply, and/or genetic makeup<ref name="Champ" />.
Some other mechanisms that can contribute to the development of OCD are: trauma, ischaemia, disordered ossification and genetic abnormalities. However, these mechanisms are not universally accepted but may be a contributing factor.<ref name="Steven" />
Vascular hypo perfusion and repeated micro-trauma may also contribute to the development of OCD. Capillary blood supply is often limited to 1 or 2 end vessels with limited collateral flow. This leads to vascular hypo perfusion.
Repeated micro-trauma could lead to a production of a relatively avascular state in the vulnerable immature capitellar chondroepiphysis.<ref name="Steven" />
== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


<br>Presentation includes pain over the joint, stiffness, feeling of [http://www.physio-pedia.com/Postero-lateral_Elbow_Instability postero-lateral elbow instability] , and stiffness after resting. This commonly affects the knee in a teenager or young adult and the elbow. It presents characteristics of a loose body: locking, giving way and recurrent effusions. <ref name="Curry" />&nbsp;Complaints of popping, clicking, or sudden “giving way,” are present especially with load bearing.<ref name="Felix" />
Presentation includes<ref name="Felix" /> <ref>Elbow OCD (Osteochondritis Dissecans). Available from: https://www.arlingtonortho.com/conditions/elbow/elbow-ocd-osteochondritis-dissecans/ (Accessed, 09/01/2022).</ref> :
 
* Lateral Pain over the joint
<br>
* Swelling of elbow
* Stiffness
* Feeling of instability
* Stiffness after resting
* Locking
* Giving way
* Popping/clicking  
* Reduced range of motion
* Painful full elbow flexion or extension


== Differential Diagnosis  ==
== Differential Diagnosis  ==


If there is no radiologic confirmation of Osteochondritis Dissecans, other diagnoses may include inflammatory arthritides inflammatory arthritis, osteoarthritis, bone cysts, and [http://www.physio-pedia.com/Septic_%28Infectious%29_Arthritis septic arthritis.]<br>A lot of other various conditions may seem to be Osteochondritis Dissecans (OCD). These are Panner’s disease, osteonecrosis, osteochondral fracture, hereditary epiphyseal dysplasia and Little Leaguer’s Elbow.&nbsp;<ref name="Steven" />  
If there is no radiological confirmation of Osteochondritis Dissecans, other diagnoses may include:
* Panner's Disease in younger Children (9-10 years)<ref name="Felix" />
* Insertional Apophysitis in pre-pubescent patients<ref name=":0" /> 
* [[Rheumatoid Arthritis|Rheumatoid arthritis]]
* [[Elbow osteoarthritis|Osteoarthritis]]<ref name="Steven" />
* Bone cysts
* [http://www.physio-pedia.com/Septic_%28Infectious%29_Arthritis Septic arthritis]
* Epicondylar avulsion fractures in older patients<ref name=":0" />
==  Diagnostic Procedures&nbsp; ==


== <br>Diagnostic Procedures&nbsp; ==
Radiographs can detect any abnormalities on the surface of the joint. Radiographs and MRI can also confirm diagnosis, monitor progress and assess for potential surgical intervention.<ref>Zbojniewicz AM, Laor T. [https://www.ncbi.nlm.nih.gov/pubmed/24698040 Imaging of osteochondritis dissecans.] Clinics in sports medicine. 2014 Apr 1;33(2):221-50.</ref> &nbsp;


Radiographs can detect any abnormalities on the surface of the joint.&nbsp;If the cartilage flake includes a piece of underlying bone, it can be seen on [http://www.physio-pedia.com/X-Rays X-ray].<ref name="Curry" /> [http://www.physio-pedia.com/MRI_Scans Magnetic Resonance Imaging] (MRI) will show any accumulation of fluid in the area and can detect any loose fragments. Computerized Tomography (CT) can detect any bony fragments, pinpoint their location and determine whether they have settled in the joint space.<br>[[Image:Elbow joint OCD lesion.jpg]] This figure shows an OCD lesion in the distal capitellum of the humeri. this figure shows a stage IV Osteochondritis Dissecans where a loose fragment of cartilage can be examined.<ref name="Curry" /><ref>Singapore Sports and Orthopaedic Clinic, 2014 (Level of Evidence 5)</ref><br>  
[[X-Rays|X-ray]] can show if the cartilage flake includes a piece of underlying bone.<ref name="Champ" />


== <br>Outcome Measures&nbsp; ==
[http://www.physio-pedia.com/MRI_Scans Magnetic Resonance Imaging] (MRI) will show any accumulation of fluid in the area and can detect any loose fragments. MRI should be considered when symptomatic patients have a normal X-Ray.<ref>Brunton LM, Anderson MW, Pannunzio ME, Khanna AJ, Chhabra AB. [https://www.ncbi.nlm.nih.gov/pubmed/16843164 Magnetic resonance imaging of the elbow: update on current techniques and indications]. The Journal of hand surgery. 2006 Jul 1;31(6):1001-11.</ref>


An outcome measure appropriate for this injury is the&nbsp;[http://www.physio-pedia.com/DASH_Outcome_Measure DASH questionnaire] which measures disabilities of the arm (under the term arm we can also understand elbow), , shoulder and hand as they relate to everyday function. A modified Andrews elbow scoring system (MAESS) is used to determine specific function of the elbow.<br>  
[[CT Scans|Computerised Tomography]] (CT) can detect any bony fragments, pinpoint their location and determine whether they have settled in the joint space.<ref>Moktassi A, Popkin CA, White LM, Murnaghan ML. [https://www.ncbi.nlm.nih.gov/pubmed/22480469 Imaging of osteochondritis dissecans]. Orthopedic Clinics. 2012 Apr 1;43(2):201-11.</ref>


<br>  
Ultrasonography is also used to assess OCD lesions <ref>Maruyama M, Takahara M, Satake H. Diagnosis and treatment of osteochondritis dissecans of the humeral capitellum. Journal of Orthopaedic Science. 2018 Mar 1;23(2):213-9.</ref>  


== Examination ==
==  Outcome Measures&nbsp; ==


Physical examination is possible to find radiocapitellar tenderness. Crepitus, decreased elbow extension and an effusion could be occurring. As told above clicking, catching or locking could also occur. These suggest OCD fragment instability and the associated loose bodies. To help confirm the diagnosis of capitellar OCD we can use the active radiocapitellar compression test. The test goes as follows: the examiner places the elbow of the patient in full extension and then he lets the patient actively pronate and supinate the forearm. (Level of Evidence 3A) This test is positive if it results in a compression across the radiocapitellar joint and which evokes lateral joint pain.<ref name="Steven" />  
An outcome measure appropriate for this injury is the&nbsp;[http://www.physio-pedia.com/DASH_Outcome_Measure DASH questionnaire] which measures disabilities of the elbow, shoulder and hand as they relate to everyday function.<ref>Schoch B, Wolf BR. [https://www.sciencedirect.com/science/article/pii/S074980631000246X Osteochondritis dissecans of the capitellum: minimum 1-year follow-up after arthroscopic debridement.] Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2010 Nov 1;26(11):1469-73.</ref><ref>MacDermid JC. [https://www.jhandtherapy.org/article/S0894-1130(01)80040-5/abstract Outcome evaluation in patients with elbow pathology: issues in instrument development and evaluation.] Journal of Hand Therapy. 2001 Apr 1;14(2):105-14.</ref>  


<br>
Additional measures may be required in terms of return to sport, especially in professional level sport.


== Medical Management&nbsp; ==
== Examination ==


Surgical management may be an option if conservative care fails or if the lesion is Grade III or higher.<br>Surgical interventions are aimed at:<br>Promoting re-vascularisation to the area<br>Debriding the area<br>Fragment stabilisation<br>Bone grafting if needed<br>Most of these procedures are done arthroscopically (minimally invasive via portal sites), although depending on the size of the loose fragments an open procedure may be required.  
=== Subjective assessment ===
* Complaints of aching post exercise or activity
* Gradually worsening symptoms<ref name="Felix" />
* Reported crepitus or popping<ref name=":1">Ruch DS. [https://www.ncbi.nlm.nih.gov/pubmed/9848588 The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy:] The Journal of Arthroscopic & Related Surgery. 1998 Nov 1;14(8):797-803.</ref>
* Increase in sport recently


<br>  
=== Objective assessment ===
* Swelling posterior-laterally<ref>Cain Jr EL, Dugas JR, Wolf RS, Andrews JR. [https://www.ncbi.nlm.nih.gov/pubmed/12860556 Elbow injuries in throwing athletes: a current concepts review]. The American journal of sports medicine. 2003 Jul;31(4):621-35.</ref>
* Loss of full extension<ref name="Felix" />
* Lateral elbow joint pain
* Positive response to valgus overload<ref name="Felix" />
* Crepitus or popping (indicating osteochondral defects)<ref name=":1" />
* Positive radio-capitellar compression test: full extension with active pronation and supination. Positive test will reproduce lateral pain<ref name="Steven" />


Operative Management<br>The mainstay of the operative management is the removal of the loose fragments and debridement of the base, also the arthroscopic evaluation of the lesion is a part of the treatment. Although most of the older literature was focused on an open management, most of the newest literature delineate the efficacy of arthroscopic surgery. The diagnostic arthroscopy of the anterior compartment of the elbow is the first step for the operative technique (Level of Evidence 2A). The most useful technique is to begin the arthroscopy with the anteromedial portal to visualise the radiocapitellar joint. The anterior part of the capitulum is mostly normal. If we notified a anterior lesion, we can use the 70° arthroscope to visualise the lesion and the lateral portal is used to treat the lesion. The anterior side of the elbow is then evaluated with a camera for loose bodies. If there are loose bodies, they are removed via an anterolateral portal. Also the fossa olecranon is evaluated for loose bodies. If there are loose bodies, they are removed via a posterior central or posterior lateral portal. The medial gutter is also evaluated for loose bodies and inflammation. If there is any inflammation or thickening of the posterolateral plica, they remove it via a posterolateral portal.<ref name="Felix" />


<br>Arthroscopic surgery can include debridement, fragment fixation, microfracturing and osteochondral autografting. Removing of the fragments alone is a minimally and common invasive procedure. The long-term results can be poor if a large osteochondral defect of the capitulum remains. An alternative procedure is the fragment fixation with a bone graft. It is difficult to fix a cartilaginous fragment securely in unhealthy subchondral bone (Level of Evidence 3A). Recurrent symptoms after a short time span can be expected in these patients. Research show us a gain in ROM about debridement, microfracturing, drilling and creating fibrocartilage. The hyaline cartilage can mostly not be restored with the techniques of treatment of capitellar OCD. The technique that can restore the hyaline cartilage is the osteochondral autografting technique. The negative point of osteochondral autografting is the need to expose the knee joint to fix the graft. But for the elbow the size of the defect is limited.&nbsp;<ref>Frank de Graaff et al., Arthroscopic Surgery in Athletes With Osteochondritis Dissecans of the Elbow, Artrhoscopy, 2011 (Level of Evidence : 3A)</ref><br> <br>
{{#ev:youtube|v=Grj5zJfrEp0}}<ref>Orthobullets. Osteochondritis Dissecans of Elbow Exam Review - Christopher S. Ahmad, MD.  
<div><br></div>
Available from: https://www.youtube.com/watch?v=Grj5zJfrEp0[Last accessed: 12/01/22]</ref>
== <span>&nbsp;</span>Physical Therapy Management ==
== Management&nbsp; ==


Conservative care for this condition include physical therapy, use of non-steroidal anti-inflammatory drugs (NSAIDs), rest from sport for 6-8 weeks, and bracing.<br>Steven A. Giuseffi states that the non-operative treatment of Osteochondritis Dissecans of the elbow still remains controversial. Lesion stability, integrity of the overlying cartilage and status of the capitellar physis are key considerations in determining the appropriate management. Lesions with an intact cartilage surface, i.e. a stable lesion, but also non-displaced lesions with cartilage compromise can be treated using a non-operative management. If an open physis, relatively preserved elbow range of motion (ROM), 20° at most, localised flattening or lucency on radiographs without evidence of defect fragmentation or instability occurs a positive prognosis could be stated. <ref name="Steven" />&nbsp;<br>This non-operative treatment consists of rest and activity modification, as such that sports and aggravating activities are ceased until symptoms resolve. This usually takes 3 to 12 weeks until the symptoms are resolved.
OCD can be managed conservatively or surgically. Surgical management may be necessary if conservative care fails, if the lesion is Grade III or higher, or if disruption of the cartilage cap continues.<ref>de Graaff F, Krijnen MR, Poolman RW, Willems WJ. [https://www.arthroscopyjournal.org/article/S0749-8063(11)00039-9/abstract Arthroscopic surgery in athletes with osteochondritis dissecans of the elbow]. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2011 Jul 1;27(7):986-93.</ref><br>


Steven A. Giuseffi also recommends the use of a hinged brace during the passing time. This protects the elbow and helps correct a natural elbow valgus and will help offload the capitellum. When the patient’s symptoms improve, gentle physical therapy and ROM-exercises could be used. At first, the brace is set at the limits of pain-free range of motion, often as limited as 60 to 90°. The brace is loosened to allow full range of motion, as the inflammation in the plica decreases and pain-free motion increases (Level of Evidence 2A), <ref name="Felix" />&nbsp;Within 2 weeks from the beginning of treatment, the patient is able to return to normal activities with the brace in place. <ref name="Felix" />&nbsp;After 3 to 6 months (usually) athletes can return to their sports activities.The patient and family should be advised of potential long-term sequelae.<br>If the patient doesn’t have a stable lesion, operative treatment could be advised. If arthroscopic debridement and drilling was used, non-operative treatment could be used postoperative. The patient will be placed in a double-hinged elbow brace within a week and gentle ROM-exercises could be used. When pain and swelling disappear, the patient may gradually participate in athletic activities in the brace. Full return to athletics could be estimated after 3-4 months. (Level of Evidence 3A) As mentioned above patients and parents should be advised of potential sequelae.&nbsp;<ref name="Steven" />  
=== Conservative management ===
* Analgesia and [[NSAIDs]]
* Bracing to offload the joint. In a hinged brace set to pain free range of movement (ROM)<ref name="Felix" />
* Ceasing sports or activities that aggravate symptoms for 6-12 weeks<ref name="Felix" />
* Activity modification
* Physiotherapy
Conservative management may not always be successful even in Grade I lesions and should be re-assessed regularly.<ref>Takahara M, Ogino T, Fukushima S, Tsuchida H, Kaneda K. [http://journals.sagepub.com/doi/abs/10.1177/03635465990270060701 Nonoperative treatment of osteochondritis dissecans of the humeral capitellum]. The American journal of sports medicine. 1999 Nov;27(6):728-32.</ref>


The patient can be situated in three phases: acute, recovery and maintenance.<br>During the acute phase the physiotherapist should advise the patient, who have an intact humeral capitellum osteochondritis dissecans lesion, to rest and to limit their activities. He/she should also teach these patients how to apply ice on their elbow. If the patient experiences a lot of pain, the physiotherapist should consider using a hinge brace to relieve this pain and only for this use. Bracing during a long period of time is not indicated as these could increase the risk of flexion contractures. As referred before it’s very important to apply ice, as this relieves the pain.&nbsp;<ref name="Patel">Shital Patel. Humeral Capitellum Osteochondritis Dissecans Treatment &amp; Management, MedScape. (Level of evidence: 3A)</ref><br>When the patient could be located in the recovery phase, after an intervention, then the physiotherapist can start with passive range-of-motion (ROM) exercises. These can be follow by active ROM exercises, this to avoid contractures. Progressive resistance training should be used as the patient can tolerate more activity and gets stronger. It hasn’t been proven in CT’s (clinical trials) but electrical stimulation may also facilitate recovery.&nbsp;<ref name="Patel" /><br>
=== Surgical management<ref name="Felix" /> ===
Arthroscopic surgery will aim to:
* Assess the anterior elbow
* Remove loose bodies and fragments
* Debride any necrotic bone
* Mirco-fracture the site to stimulate increased blood flow<ref name=":2">Bojanić I, Ivković A, Borić I. [https://link.springer.com/article/10.1007/s00167-005-0693-y Arthroscopy and microfracture technique in the treatment of osteochondritis dissecans of the humeral capitellum: report of three adolescent gymnasts.] Knee Surgery, Sports Traumatology, Arthroscopy. 2006 May 1;14(5):491-6.</ref>
In some cases a large fragment may need to be re-attached to the capitellum which will be done via K wire or screw fixation.<ref name="Felix" /> In severe cases osteochondral grafting may be required.<ref>Jones KJ, Wiesel BB, Sankar WN, Ganley TJ. [https://journals.lww.com/pedorthopaedics/Abstract/2010/01000/Arthroscopic_Management_of_Osteochondritis.2.aspx Arthroscopic management of osteochondritis dissecans of the capitellum: mid-term results in adolescent athletes]. Journal of Pediatric Orthopaedics. 2010 Jan 1;30(1):8-13.</ref> 
== Physiotherapy Management ==


The maintenance phase consists of continued use of strengthening and ROM exercises for the elbow. It is also important to prevent further injuries by taking measures protecting the elbow. The physiotherapist could advise patients of the significance of a wrist/finger program and a shoulder program. Strengthening and ROM exercises should also be the main focus during these programs.&nbsp;<ref name="Patel" /><br>  
=== Conservative ===
The initial stage should be focused on advice, education and pain management. This can be through use of NSAIDs, activity modification, cessation of sports and/or bracing for 6-12 weeks.<ref name="Felix" />
[[File:Elbow brace.jpg|none|thumb|500x500px|Hinged elbow brace<ref name=":3">Maniwa S, Tadenuma T, Sakai Y, Aoki A, Yamagami N, Yamamoto S, Uchio Y. [https://www.jstage.jst.go.jp/article/prm/2/0/2_20170002/_html/-char/en Elbow Brace Promotes Postoperative Rehabilitation of Osteochondral Graft in Young Athletes with Osteochondritis Dissecans of the Humeral Capitellum]. Progress in Rehabilitation Medicine. 2017;2:20170002.</ref>]]


Analytic physiotherapy consists of specific techniques. Those techniques could be used for traumatic osteoarticular pathologies, micro-traumas, functional or postural pathologies. This states that it could be used for inflammatory pathologies as osteochondritis.<br>  
A hinged brace can be used to help offload the joint and any valgus pressure. This can be set to any pain free ROM and gradually increased as swelling and symptoms decrease.<ref name="Felix" /><br>When pain has settled, management would be to gradually introduce full ROM and strengthening exercises out of a painful range.


The treatment starts with specific mobilisation meaning to release blocked and displaced joints. These mobilisations are calm and progressive. These movements are executed in the initial position, this to evade tension on soft tissue. Researchers express on the demanded cyclic force that should be given. The cyclic force will lead to a normal physiology of chondrocytes. Constant pressure will result in destruction of the cartilage. Switching up the contraction and relaxation of muscles during these techniques is also important. Following these steps will result in regeneration of the articular structures to an optimal state.&nbsp;<ref name="Haye">Michel Haye, La kinésithérapie analytique thérapie manuelle selon le concept de Sohier,Profession Kinésithérapeute, 2007 (Level of evidence: 3A)</ref><br><br>  
The patient can start return to play exercises as long as symptoms are not an issue.<ref name="Felix" /><ref name=":3" /> 
=== Post-operative ===
Initially post operatively the patient would likely be on a continuous passive movement machine until put in a hinge brace. Gentle circulation and residual joint ROM exercises can be started (fingers, wrist and shoulder). <ref name="Felix" />


== Key Evidence  ==
At three weeks post operatively ROM and gradual strengthening may be commenced however; this may vary depending on consultant preference. Some post operative protocols state no strengthening exercises until three months.<ref name=":4">Ahmad CS, ElAttrache NS. [http://www.kinex.cl/papers/Hombro/Treatment%20of%20Capitellar%20Osteochondritis.pdf Treatment of Capitellar Osteochondritis Dissecans.] Techniques in Shoulder and Elbow Surgery 2006 7(4):169–174.</ref>


A study published in 2008 reports a favorable prognosis of up to 90% for patients who are treated conservatively in the stage I of this condition. Patients who were in stage II had about a 53% of a good prognosis with conservative treatment. Duration of this treatment was just under 15 months in the first stage and 13 months in the second stage. About 78% of stage I and 53% of stage II patients were able to return to competitive baseball. Mean ages for these groups were about 12 years in stage I and 14 years of age in stage II. This study is a level III study, and more research should be done to support these results.<br>Another study performed in 2006 looks at the surgical considerations for osteochondritis dissecans. The article looks at 15 patients with a mean age of 28 that underwent elbow arthroscopic debridement for this condition. These patients were classified using the Baumgarten system and were graded during arthroscopy. They looked at the patients about 4 years out of surgery and found a significant decrease in pain levels and function was improved from a “poor” to an “excellent” status per the modified Andrews elbow scoring system. About 80% of these patients were able to return to the same level of sport while all of the patients were able to return to work.<br>Factors that should be considered are age, activity level for the studies above. Clearly more research needs to be done to determine best practice when it comes to treatment of osteochondritis dissecans.
Return to play will depend on sport and pain.<ref name="Felix" /><ref name=":4" /> Athletes have the potential to return to their pre-injury level if motivation and compliance with rehabilitation allows.<ref name=":2" />


== Resources  ==
== Complications <ref>Osteochondritis Dissecans. Available from: https://www.orthobullets.com/shoulder-and-elbow/3085/osteochondritis-dissecans-of-elbow (Accessed, 12/01/22).</ref> ==


Resources we used for pictures:<br>Fig 1&nbsp;: https://www.youtube.com/watch?v=sfAxCsv_Hes (12)<br>Fig. 2: http://radiology.casereports.net/index.php/rcr/article/view/18/161 (11)<br>Fig. 3: http://www.seattlechildrens.org/medical-conditions/bone-joint-muscle-conditions/cartilage-conditions/osteochondritis-dissecans/ (16)<br>Fig. 4: http://www.boneclinic.com.sg/patient-education/child-orthopaedics/adolescent-osteochondritis-dissecans/ (17)<br>
* [[Elbow]] stiffness
* Pain
* Inability to return to sports
* [[Arthritis]]


Books:<br>H.L.F. Currey,Essentials of rheumatology, 1988, p166 [9]<br><br>
== Resources  ==
[http://www.orthopaedicscore.com/scorepages/disabilities_of_arm_shoulder_hand_score_dash.html DASH Questionnaire]


[https://www.uptodate.com/contents/osteochondritis-dissecans-ocd-clinical-manifestations-and-diagnosis#references Osteochondritis Dissecans: Clinical manifestation and diagnosis]
== Clinical Bottom Line&nbsp; ==
== Clinical Bottom Line&nbsp; ==


Osteochondritis Dissecans <ref name="Steven" />&nbsp;is, in adolescent athletes, an increasingly common cause of elbow dysfunction and elbow pain. [6] It can lead to additional conditions which lead to a complex situation. There are multiple mechanisms that lead to OCD: trauma, ischemia, disordered ossification and genetic abnormalities. What typically happens is that one or more flakes of articular cartilage separates and forms loose bodies within the joint. <ref name="Steven" />&nbsp;The separated flakes remain alive and frequently ossify. <ref name="Patel" />&nbsp;Most lesions involve the capitellum, typically the central or lateral portion, but also the radial head, the olecranon of the ulnae and the trochlea humeri. <ref name="Felix" />&nbsp;OCD can also be caused by a vascular dysfunction or microtrauma. <ref name="Steven" />&nbsp;Main characteristics of the illness that are commonly mentioned are locking, giving away and recurrent effusions. <ref name="Felix" />&nbsp;As far as the differential diagnosis goes, we can quote Panner’s disease, osteonecrosis, osteochondral fracture, hereditary epiphyseal dysplasia and Little Leaguer’s Elbow. <ref name="Steven" />&nbsp;Examination can be done using the active radiocapitellar compression test, in case of lateral joint pain evocation the test is considered positive. <ref name="Steven" />&nbsp;For medical management, the use of arthroscopic surgery is one of the options. <ref name="Felix" />&nbsp;As for the physical therapy management it still remains controversial, although there is a vast description of the possibilities described.&nbsp;<ref name="Steven" />
Osteochondritis Dissecans is, in adolescent athletes, an increasingly common cause of elbow dysfunction and elbow pain.<ref name="Steven" /> It can eventually lead to osteoarthritis and other elbow pathologies if not treated. The mechanisms of injury can be multi-factorial but most common in the young sporting population.  
 


OCD occurs when one or more flakes of articular cartilage separates and forms loose bodies within the joint. <ref name="Steven" /> The separated flakes remain alive and frequently ossify causing popping and crepitus.<ref name="Felix" />


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
Main characteristics of the disease that are commonly mentioned are locking, giving away, stiffness and recurrent effusions. <ref name="Felix" />&nbsp;
<div class="researchbox"><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1d5iJ1ljAjCoAYm05e0slhzh1Ed8d7b15qso9aqZRVRnYQUAO</rss> http://www.ncbi.nlm.nih.gov/pubmed/25953486<br>http://www.ncbi.nlm.nih.gov/pubmed/20188271<br>http://www.ncbi.nlm.nih.gov/pubmed/25264040<br>http://www.ncbi.nlm.nih.gov/pubmed/24698041<br>http://www.ncbi.nlm.nih.gov/pubmed/24698040<br> </div>
== References  ==


References will automatically be added here, see [[Adding References|adding references tutorial]]. <ref>Mayo Clinic. Osteochondritis Dissecans. http://www.mayoclinic.com/health/osteochondritis-dissecans/DS00741 (accessed 6/13/09).</ref> <ref>Rahusen F Th G, et al. Results of arthroscopic debridement for osteochondritis dissecans of the elbow. B J Sports Med 2006;40:966-969. Abstract: http://bjsportmed.com/cgi/content/abstract/40/12/966 (accessed 6/25/09).</ref><ref>Matsuura T, et al. Conservative Treatment for Osteochondrosis of the Humeral Capitellum. Am J Sports Med. 2008;36(5): 868-872. Abstract: http://ajs.sagepub.com/content/36/5/868.abstract (accessed 6/18/09).</ref> <ref>O’Sullivan S, Siegelman R. National Physical Therapy Examination Review &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Study Guide. Evanston, IL: International Educational Resources Ltd, 2006.</ref> <ref>Patient UK. http://www.patient.co.uk/showdoc/40001133/ (accessed 6/13/09)</ref> <br> <references />  
Examination can be done using the active radiocapitellar compression test, in case of lateral joint pain evocation the test is considered positive. <ref name="Steven" /> For medical management, the use of arthroscopic surgery is the main route of management to remove the bony fragments. <ref name="Felix" /> Physiotherapy post-operative management is fairly standard and will vary depending on consultant preference, however, conservative management mainly reports to avoid symptoms and aggravating activities until the bony fragments have healed.<ref name="Felix" />
== References    ==
<references />  


[[Category:EIM_Residency_Project]]
[[Category:EIM_Residency_Project]]
[[Category:Primary Contact]]
[[Category:Sports Medicine]]
[[Category:Sports Injuries]]
[[Category:Musculoskeletal/Orthopaedics]]

Latest revision as of 17:18, 12 January 2022

Original Editor - Pamela Gonzalez Top Contributors - Pamela Gonzalez, Abbey Wright, Kirenga Bamurange Liliane, Admin, Rachael Lowe, Lucas De Bondt, 127.0.0.1, Eric Robertson, Jason Coldwell, WikiSysop, Claire Knott and Wanda van Niekerk  


Definition/Description [edit | edit source]


Osteochondritis Dissecans (OCD) is defined as an inflammatory pathology of bone and cartilage. This can result in localized necrosis and fragmentation of bone and cartilage.

Arrow points to calcific flake in distal capitellum[1]

OCD of the elbow is most commonly seen in the sporting adolescent population (ages 12-14) in particular throwing sports or upper limb dominant sports such as baseball or hockey.[2][3] Hence the common term "Little league elbow".[4]

In the elbow, the most common area affected is the capitellum, although it has been reported to affect the olecranon and the trochlea.[5][3] OCD can mean one or more flakes of articular cartilage have become separated. Which form loose bodies within the joint. The separated flakes can then ossify due to nourishment by the synovial fluid.[6] The cartilage is damaged and can form a loose body.[7]


In the long term OCD can lead to subsequent degenerative arthritis or osteoarthritis.[2]

Clinically Relevant Anatomy[edit | edit source]

Involved anatomy of this disorder includes the radial head or the central and/or lateral aspect of the capitellum.

Most OCD lesions of the elbow involve the capitellum, typically the central or lateral portion, but also the radial head, the olecranon of the ulna and the trochlea humeri.[2]

Epidemiology / Aetiology[edit | edit source]

Ostechondritis of the humeral capitellum is secondary to repetitive compression forces between radial head and capitellum.

Repetitive high stress forces on the joint can result in a series of minor injuries on the elbow that can eventually lead to bony fragmentation and ultimately detachment of the bony fragment from the bone.[3]

Many factors are associated with the aetiology and development of avascular necrosis. They include the following components: genetics, anatomy, trauma, vascular, metabolic, haematogenous, endocrine, nutritional and inflammatory disorders.[8]

Commonly seen in the adolescent sporting population; who partake in repetitive throwing or overhead activities such as baseball and gymnastics.[7] More frequently seen in males (ages 10-14) than females and often affecting the dominant arm.[3][7]

Stages of osteochondritis dissecans:[5][edit | edit source]

Stage I[edit | edit source]

Thickening of cartilage and a stable lesion

Stage II[edit | edit source]

Articular cartilage interrupted and a stable lesion low signal rim behind fragment showing that there is fibrous attachment

Stage III[edit | edit source]

Articular cartilage interrupted, Unstable high signal changes behind fragment and underlying subchondral bone

Stage IV[edit | edit source]

Loose body Unstable

[9]

The cause of OCD is likely multi-factorial. Causes of this pathology normally include injury or repetitive stress on the joint, lack of blood supply, and/or genetic makeup[5].

Some other mechanisms that can contribute to the development of OCD are: trauma, ischaemia, disordered ossification and genetic abnormalities. However, these mechanisms are not universally accepted but may be a contributing factor.[2]

Vascular hypo perfusion and repeated micro-trauma may also contribute to the development of OCD. Capillary blood supply is often limited to 1 or 2 end vessels with limited collateral flow. This leads to vascular hypo perfusion.

Repeated micro-trauma could lead to a production of a relatively avascular state in the vulnerable immature capitellar chondroepiphysis.[2]

Characteristics/Clinical Presentation[edit | edit source]

Presentation includes[3] [10] :

  • Lateral Pain over the joint
  • Swelling of elbow
  • Stiffness
  • Feeling of instability
  • Stiffness after resting
  • Locking
  • Giving way
  • Popping/clicking
  • Reduced range of motion
  • Painful full elbow flexion or extension

Differential Diagnosis[edit | edit source]

If there is no radiological confirmation of Osteochondritis Dissecans, other diagnoses may include:

Diagnostic Procedures [edit | edit source]

Radiographs can detect any abnormalities on the surface of the joint. Radiographs and MRI can also confirm diagnosis, monitor progress and assess for potential surgical intervention.[11]  

X-ray can show if the cartilage flake includes a piece of underlying bone.[5]

Magnetic Resonance Imaging (MRI) will show any accumulation of fluid in the area and can detect any loose fragments. MRI should be considered when symptomatic patients have a normal X-Ray.[12]

Computerised Tomography (CT) can detect any bony fragments, pinpoint their location and determine whether they have settled in the joint space.[13]

Ultrasonography is also used to assess OCD lesions [14]

Outcome Measures [edit | edit source]

An outcome measure appropriate for this injury is the DASH questionnaire which measures disabilities of the elbow, shoulder and hand as they relate to everyday function.[15][16]

Additional measures may be required in terms of return to sport, especially in professional level sport.

Examination[edit | edit source]

Subjective assessment[edit | edit source]

  • Complaints of aching post exercise or activity
  • Gradually worsening symptoms[3]
  • Reported crepitus or popping[17]
  • Increase in sport recently

Objective assessment[edit | edit source]

  • Swelling posterior-laterally[18]
  • Loss of full extension[3]
  • Lateral elbow joint pain
  • Positive response to valgus overload[3]
  • Crepitus or popping (indicating osteochondral defects)[17]
  • Positive radio-capitellar compression test: full extension with active pronation and supination. Positive test will reproduce lateral pain[2]


[19]

Management [edit | edit source]

OCD can be managed conservatively or surgically. Surgical management may be necessary if conservative care fails, if the lesion is Grade III or higher, or if disruption of the cartilage cap continues.[20]

Conservative management[edit | edit source]

  • Analgesia and NSAIDs
  • Bracing to offload the joint. In a hinged brace set to pain free range of movement (ROM)[3]
  • Ceasing sports or activities that aggravate symptoms for 6-12 weeks[3]
  • Activity modification
  • Physiotherapy

Conservative management may not always be successful even in Grade I lesions and should be re-assessed regularly.[21]

Surgical management[3][edit | edit source]

Arthroscopic surgery will aim to:

  • Assess the anterior elbow
  • Remove loose bodies and fragments
  • Debride any necrotic bone
  • Mirco-fracture the site to stimulate increased blood flow[22]

In some cases a large fragment may need to be re-attached to the capitellum which will be done via K wire or screw fixation.[3] In severe cases osteochondral grafting may be required.[23]

Physiotherapy Management[edit | edit source]

Conservative[edit | edit source]

The initial stage should be focused on advice, education and pain management. This can be through use of NSAIDs, activity modification, cessation of sports and/or bracing for 6-12 weeks.[3]

Hinged elbow brace[24]

A hinged brace can be used to help offload the joint and any valgus pressure. This can be set to any pain free ROM and gradually increased as swelling and symptoms decrease.[3]
When pain has settled, management would be to gradually introduce full ROM and strengthening exercises out of a painful range.

The patient can start return to play exercises as long as symptoms are not an issue.[3][24]

Post-operative[edit | edit source]

Initially post operatively the patient would likely be on a continuous passive movement machine until put in a hinge brace. Gentle circulation and residual joint ROM exercises can be started (fingers, wrist and shoulder). [3]

At three weeks post operatively ROM and gradual strengthening may be commenced however; this may vary depending on consultant preference. Some post operative protocols state no strengthening exercises until three months.[25]

Return to play will depend on sport and pain.[3][25] Athletes have the potential to return to their pre-injury level if motivation and compliance with rehabilitation allows.[22]

Complications [26][edit | edit source]

Resources[edit | edit source]

DASH Questionnaire

Osteochondritis Dissecans: Clinical manifestation and diagnosis

Clinical Bottom Line [edit | edit source]

Osteochondritis Dissecans is, in adolescent athletes, an increasingly common cause of elbow dysfunction and elbow pain.[2] It can eventually lead to osteoarthritis and other elbow pathologies if not treated. The mechanisms of injury can be multi-factorial but most common in the young sporting population.

OCD occurs when one or more flakes of articular cartilage separates and forms loose bodies within the joint. [2] The separated flakes remain alive and frequently ossify causing popping and crepitus.[3]

Main characteristics of the disease that are commonly mentioned are locking, giving away, stiffness and recurrent effusions. [3] 

Examination can be done using the active radiocapitellar compression test, in case of lateral joint pain evocation the test is considered positive. [2] For medical management, the use of arthroscopic surgery is the main route of management to remove the bony fragments. [3] Physiotherapy post-operative management is fairly standard and will vary depending on consultant preference, however, conservative management mainly reports to avoid symptoms and aggravating activities until the bony fragments have healed.[3]

References[edit | edit source]

  1. ↑ Folio LR, Craig SH, Wright GA, Battaglia MJ. Loose body in elbow of a baseball player: arthroscopic/radiologic correlation. Radiology case reports. 2006 Jan 1;1(2):62-5.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Giuseffi SA, Field LD. Osteochondritis dissecans of the elbow. Operative Techniques in Sports Medicine. 2014 Jun 1;22(2):148-55.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 3.20 3.21 Felix H. Savoie, III, MD. Osteochondritis Dissecans of the Elbow. Operative Techniques in Sports Medicine. 2008 16:187-193
  4. ↑ 4.0 4.1 4.2 Klingele KE, Kocher MS. Little league elbow. Sports Medicine. 2002 Dec 1;32(15):1005-15.
  5. ↑ 5.0 5.1 5.2 5.3 Baker III CL, Romeo AA, Baker Jr CL. Osteochondritis dissecans of the capitellum. The American journal of sports medicine. 2010 Sep;38(9):1917-28.
  6. ↑ Curry H. Essentials of Rheumatology. 1st ed. Churchill Livingstone; 1988.
  7. ↑ 7.0 7.1 7.2 Matsuura T, Suzue N, Iwame T, Nishio S, Sairyo K. Prevalence of osteochondritis dissecans of the capitellum in young baseball players: results based on ultrasonographic findings. Orthopaedic journal of sports medicine. 2014 Aug 11;2(8):2325967114545298.
  8. ↑ D Bain G, Pederzini L, Poehling G. Osteochondritis dissecans of the elbow: state of the art. Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine. 2017 Jan 1;2(1):47-57.
  9. ↑ Frank Holowka. Osteochondritis Dissecans presentation. Available from: https://www.youtube.com/watch?v=1rPRxYGp08w&t=2s [last accessed: 11/03/14]
  10. ↑ Elbow OCD (Osteochondritis Dissecans). Available from: https://www.arlingtonortho.com/conditions/elbow/elbow-ocd-osteochondritis-dissecans/ (Accessed, 09/01/2022).
  11. ↑ Zbojniewicz AM, Laor T. Imaging of osteochondritis dissecans. Clinics in sports medicine. 2014 Apr 1;33(2):221-50.
  12. ↑ Brunton LM, Anderson MW, Pannunzio ME, Khanna AJ, Chhabra AB. Magnetic resonance imaging of the elbow: update on current techniques and indications. The Journal of hand surgery. 2006 Jul 1;31(6):1001-11.
  13. ↑ Moktassi A, Popkin CA, White LM, Murnaghan ML. Imaging of osteochondritis dissecans. Orthopedic Clinics. 2012 Apr 1;43(2):201-11.
  14. ↑ Maruyama M, Takahara M, Satake H. Diagnosis and treatment of osteochondritis dissecans of the humeral capitellum. Journal of Orthopaedic Science. 2018 Mar 1;23(2):213-9.
  15. ↑ Schoch B, Wolf BR. Osteochondritis dissecans of the capitellum: minimum 1-year follow-up after arthroscopic debridement. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2010 Nov 1;26(11):1469-73.
  16. ↑ MacDermid JC. Outcome evaluation in patients with elbow pathology: issues in instrument development and evaluation. Journal of Hand Therapy. 2001 Apr 1;14(2):105-14.
  17. ↑ 17.0 17.1 Ruch DS. The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 1998 Nov 1;14(8):797-803.
  18. ↑ Cain Jr EL, Dugas JR, Wolf RS, Andrews JR. Elbow injuries in throwing athletes: a current concepts review. The American journal of sports medicine. 2003 Jul;31(4):621-35.
  19. ↑ Orthobullets. Osteochondritis Dissecans of Elbow Exam Review - Christopher S. Ahmad, MD. Available from: https://www.youtube.com/watch?v=Grj5zJfrEp0[Last accessed: 12/01/22]
  20. ↑ de Graaff F, Krijnen MR, Poolman RW, Willems WJ. Arthroscopic surgery in athletes with osteochondritis dissecans of the elbow. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2011 Jul 1;27(7):986-93.
  21. ↑ Takahara M, Ogino T, Fukushima S, Tsuchida H, Kaneda K. Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. The American journal of sports medicine. 1999 Nov;27(6):728-32.
  22. ↑ 22.0 22.1 Bojanić I, Ivković A, Borić I. Arthroscopy and microfracture technique in the treatment of osteochondritis dissecans of the humeral capitellum: report of three adolescent gymnasts. Knee Surgery, Sports Traumatology, Arthroscopy. 2006 May 1;14(5):491-6.
  23. ↑ Jones KJ, Wiesel BB, Sankar WN, Ganley TJ. Arthroscopic management of osteochondritis dissecans of the capitellum: mid-term results in adolescent athletes. Journal of Pediatric Orthopaedics. 2010 Jan 1;30(1):8-13.
  24. ↑ 24.0 24.1 Maniwa S, Tadenuma T, Sakai Y, Aoki A, Yamagami N, Yamamoto S, Uchio Y. Elbow Brace Promotes Postoperative Rehabilitation of Osteochondral Graft in Young Athletes with Osteochondritis Dissecans of the Humeral Capitellum. Progress in Rehabilitation Medicine. 2017;2:20170002.
  25. ↑ 25.0 25.1 Ahmad CS, ElAttrache NS. Treatment of Capitellar Osteochondritis Dissecans. Techniques in Shoulder and Elbow Surgery 2006 7(4):169–174.
  26. ↑ Osteochondritis Dissecans. Available from: https://www.orthobullets.com/shoulder-and-elbow/3085/osteochondritis-dissecans-of-elbow (Accessed, 12/01/22).
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