Courtesy: Nirav Pandya MD, Chief of Paediatric Orthopaedics, University of California at San Francico, California, USA

Definition

Osteochondritis Dissecans (OCD) of the capitellum is an injury involving the articular cartilage and subchondral bone of the capitellum.

It is thought to result from:

• Repetitive valgus and compressive loading of the elbow
• Relative vascular insufficiency during skeletal development
• Repetitive microtrauma from sports participation

---

Why Is It Becoming More Common?

Contributing factors include:

• Early sports specialization
• Year round participation in a single sport
• High training volumes
• Increased competitive pressure

Prevention Rule

Weekly training hours should not exceed the athlete’s age.

Examples:

• 12 year old ? ? 12 hours/week
• 15 year old ? ? 15 hours/week

Encourage participation in multiple sports rather than year round single sport specialization.

---

Epidemiology

Typical Patient

• Age: 12 to 19 years
• Predominantly males
• Adolescent athletes

High Risk Sports

• Baseball pitchers
• Gymnasts
• Tennis players
• Throwing athletes

---

Pathophysiology

Repetitive loading causes compression between:

• Capitellum
• Radial head

This leads to:

• Cartilage injury
• Subchondral bone damage
• Fragment instability
• Loose body formation

---

Clinical Presentation

Symptoms

Lateral Elbow Pain

The hallmark symptom.

Activity Related Pain

• Throwing
• Gymnastics
• Racquet sports

Mechanical Symptoms

• Locking
• Catching
• Clicking

Performance Decline

• Reduced throwing velocity
• Loss of control
• Decreased athletic performance

---

Important History

Look for:

• Overuse history
• High training volume
• Year round participation
• Pain during sports activity
• Mechanical symptoms

---

Clinical Examination

Findings

• Tenderness over lateral capitellum
• Reduced elbow range of motion
• Extension loss
• Locking episodes
• Stiffness

Assess the Entire Kinetic Chain

Evaluate:

• Glenohumeral internal rotation
• Shoulder motion
• Core strength
• Lower limb strength
• Throwing mechanics

---

Differential Diagnosis

Panner Disease vs Capitellar OCD

Feature	Panner Disease	Capitellar OCD
Age	6 to 10 years	12 to 19 years
Pain	Diffuse	Localized lateral pain
X ray	Diffuse capitellar involvement	Focal lesion
Prognosis	Self limiting	May require surgery

Key Pearl

Panner disease occurs in younger children and generally heals with observation.

OCD occurs in older adolescents and may progress to instability and loose bodies.

---

Imaging

Plain Radiographs

May show:

• Capitellar lucency
• Flattening
• Fragmentation
• Loose bodies

---

MRI (Most Important Investigation)

MRI helps determine:

• Stability of lesion
• Cartilage integrity
• Presence of loose bodies
• Healing potential

MRI Signs of Instability

• Fluid behind the lesion
• Fragmentation
• Cyst formation
• Cartilage disruption

---

Treatment

Non Operative Treatment

Indications

• Stable lesion
• Small lesion
• Open growth plates
• Intact cartilage
• No fluid behind lesion

Treatment

• Rest
• Activity modification
• Temporary immobilization if required
• Cessation of throwing sports

Outcomes

Best results occur in younger patients with open physes and stable lesions.

---

Operative Treatment

Indications:

• Unstable lesion
• Loose body formation
• Failed conservative treatment
• Closed growth plates
• Mechanical symptoms

---

1. Fragment Fixation

Indications

• Early unstable lesions
• Viable osteochondral fragment
• Good cartilage quality

Advantages

• Preserves native cartilage
• Excellent healing when performed early

---

2. Arthroscopic Debridement and Microfracture

Procedure

• Remove unstable cartilage
• Debride lesion
• Create microfracture holes to stimulate fibrocartilage formation

Results

• Approximately 60% return to sport
• Less predictable in elite athletes

Limitation

Fibrocartilage is biomechanically inferior to native hyaline cartilage.

---

3. Osteochondral Autograft Transfer (OATS)

Current Gold Standard

Procedure:

• Harvest osteochondral plug from the knee
• Transfer cartilage and subchondral bone to capitellar defect

Advantages

• Restores hyaline cartilage
• Excellent durability
• Highest return to sport rates

Best Candidates

• Competitive athletes
• Large lesions
• Failed previous procedures

---

4. Osteochondral Allograft

Indications

• Large lesions
• Desire to avoid donor site morbidity

Advantages

• No donor site pain
• Ability to reconstruct large defects

---

Poor Prognostic Factors

Associated with worse outcomes:

• Older age
• Closed growth plates
• Large lesions
• Unstable lesions
• Cyst formation
• Significant motion loss
• Elite overhead athletes

---

Causes of Treatment Failure

• Early return to sport
• Persistent overuse
• Poor rehabilitation compliance
• Failure to correct throwing mechanics
• Untreated kinetic chain abnormalities

---

Management of Failed Cases

Options include:

• Revision OATS procedure
• Osteochondral allograft transplantation
• Correction of biomechanical abnormalities
• Modification of sports participation

In some athletes, changing to a lower stress sport may provide the most reliable long term solution.

---

Key Clinical Pearls

• Lateral elbow pain in an adolescent athlete should be considered OCD until proven otherwise.
• MRI is the most important investigation for staging and treatment planning.
• Stable lesions in skeletally immature athletes may heal with non operative treatment.
• Microfracture produces fibrocartilage and has limited success in elite athletes.
• OATS currently provides the most predictable return to sport in high demand athletes.
• Prevention through limiting overuse and avoiding early sports specialization remains the best treatment.