Osteochondritis Dissecans of the Elbow

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Definition/Description 

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

Arrow points to calcific flake in distal capitellum

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. Hence the common term "Little league elbow".

In the elbow, the most common area affected is the capitellum, although it has been reported to affect the olecranon and the trochlea. 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. The cartilage is damaged and can form a loose body.

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

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 ulna and the trochlea humeri.

Epidemiology / Aetiology

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.

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

Stages of osteochondritis dissecans:

Stage I

Thickening of cartilage and a stable lesion

Stage II

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

Stage III

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

Stage IV

Loose body Unstable

The cause of OCD is likely multifactorial. Causes of this pathology normally include injury or repetitive stress on the joint, lack of blood supply, and/or genetic makeup.

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.

Vascular hypo perfusion 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 hypo perfusion.

Repeated microtrauma could lead to a production of a relatively avascular state in the vulnerable immature capitellar chondroepiphysis.

Characteristics/Clinical Presentation

Presentation includes:

• Lateral Pain over the joint
• Stiffness
• Feeling of instability
• Stiffness after resting
• Locking
• Giving way
• Popping/clicking

Differential Diagnosis

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

• Panner's Disease in younger Shildren (9-10 years)
• Insertional Apophysitis in pre-pubescent patients 
• Rheumatoid arthritis
• Osteoarthritis
• Bone cysts
• Septic arthritis
• Epicondylar avulsion fractures in older patients

Diagnostic Procedures 

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.  

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

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.

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

Outcome Measures 

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.

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

Examination

Subjective assessment

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

Objective assessment

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

Management 

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.

Conservative management

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

Surgical management

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

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

Physiotherapy Management

Conservative

Initial management

This 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.

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.

The patient can be situated in three phases: acute, recovery and maintenance.
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. 
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. 

Post-operative

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. 

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. 

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.

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. 

Key Evidence

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.
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.
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.

Resources

DASH Questionnaire

Books:
H.L.F. Currey,Essentials of rheumatology, 1988, p166 [9]

Clinical Bottom Line 

Osteochondritis Dissecans  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.  The separated flakes remain alive and frequently ossify.  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.  OCD can also be caused by a vascular dysfunction or microtrauma.  Main characteristics of the illness that are commonly mentioned are locking, giving away and recurrent effusions.  As far as the differential diagnosis goes, we can quote Panner’s disease, osteonecrosis, osteochondral fracture, hereditary epiphyseal dysplasia and Little Leaguer’s Elbow.  Examination can be done using the active radiocapitellar compression test, in case of lateral joint pain evocation the test is considered positive.  For medical management, the use of arthroscopic surgery is one of the options.  As for the physical therapy management it still remains controversial, although there is a vast description of the possibilities described.