Chondral Injuries

9 Interesting Facts of Chondral Injuries 

1. Chondral lesions of the elbow may present as acute or repetitive injuries.
2. Osteochondritis dissecans is a condition that may develop spontaneously or more commonly in juvenile athletes (“little leaguer’s elbow”).
3. The pathology consists of localized avascular necrosis with subsequent loss of structural support for the adjacent cartilage.
4. The cause is thought to be valgus overload of the radiocapitellar joint.
5. This condition is commonly found in young throwing athletes (little leaguers) and gymnasts.
6. Lateral elbow joint pathology may be caused by or associated with medial collateral ligament instability.
7. The typical radiologic finding is a posteromedial osteophyte of the olecranon process.
8. This condition commonly leads to the development of loose bodies.
9. Osteochondrosis of the capitellum (Panner disease) is a related condition in children younger than the age of 10 years.

History

• •Patients may present after acute injury.
  • •Preceding injuries include elbow dislocation and periarticular fractures.
  • •The mechanism most commonly reported is a fall onto the outstretched supinated hand.
• •Chronic injuries leading to intra-articular pathology are commonly related to repetitive valgus stress, as seen in throwers and gymnasts.
• •Patients typically report elbow pain with activity, decreased performance (throwing speed), stiffness, and swelling.
• •Osteophytes and loose bodies may lead to mechanical symptoms with elbow range of motion such as locking and catching of the elbow.

Physical Examination

• •Most commonly, the elbow will have lateral tenderness with crepitus over the radiocapitellar joint.
• •Loss of terminal extension with a 15- to 20-degree flexion contracture may be one of the earliest findings.
• •Swelling is commonly present.

Imaging

• •Plain radiographs including anteroposterior, lateral, and oblique views of the elbow may show fragmented subchondral bone, subchondral lucencies, and irregular ossification.
  • •Osteophytes and loose bodies may be appreciated at later stages of the disease.
• •Magnetic resonance imaging of the elbow can be helpful to detect loose bodies not visible on plain radiographs, avascular necrosis, and associated ligament damage.
• •Elbow arthroscopy allows direct visualization and grading of osteochondritis dissecans and at the same time allows treatment of certain conditions

Grading of Osteochondrosis Lesions

Grade	Description	Treatment
I	Softening of cartilage	Drilling
II	Fibrillation and fissures	Drilling, removal of frayed portions to stable rim
III	Stable osteochondral fragment	Drilling and removal or fixation for larger fragments
IV	Loose but nondisplaced	Drilling or fixation of large fragments
V	Loose body	Drilling, mosaicplasty, or OATS for larger defects

OATS, Osteochondral autografting transplant system.

Differential Diagnosis

• •Lateral epicondylitis: lateral tenderness and pain with passive stretch of the common extensor mechanism
• •Panner disease: younger patients with avascular necrosis of the capitellum
• •Plica: mechanical symptoms, often a palpable catch, most commonly lateral
• •Posterolateral rotatory instability: pain with pushing up from a chair
• •Synovial osteochondromatosis: multiple loose bodies without evidence of chondral injury

Treatment

• •Nonoperative treatment should be attempted for grade I and II lesions with no detachment or loose bodies.
• •Treatment consists of 4 weeks of complete activity restriction, with physical therapy for strengthening and range of motion, followed by a progressive throwing program.
  • •Preinjury performance levels can be reached within 3 to 4 months.
• •Operative treatment is indicated after failure of conservative treatment for grade I and II lesions.
  • •Operative treatment is also indicated for any patient with higher-grade osteochondritis dissecans with evidence of unstable fragments or loose bodies and progressive or fixed joint contracture.
  • •Surgical treatment options include elbow arthroscopy with removal of loose bodies and contracture release, drilling of the lesions, fixation of larger fragments, and osteochondral autografting transplant system (OATS).
  • •In high-level athletes with defects >1 cm², OAT has been shown to achieve return to play at previous level.
  • •Subchondral bone and cartilage are transferred in a plug from the knee to the elbow.
• •The prognosis varies with the grade of disease.
• •Overall surgical treatment can improve elbow range of motion and eliminate mechanical symptoms.
• •The best results are accomplished after removal of isolated loose bodies with minimal morbidity and early return to full function.
• •Patients should be referred for surgical treatment in the presence of mechanical symptoms or failure to progress with conservative treatment.

Troubleshooting

• •Little league pitchers with chondral injury secondary to valgus overload from repetitive throwing motions are a particularly challenging group of patients to treat.
• •The majority of symptomatic elbows can be treated with activity modification and periods of rest followed by gradual return to throwing.
• •Unfortunately, patients and their ambitious parents are often too impatient to comply with the suggested treatment course; close supervision and reinforcement of the treatment plan may be necessary.

Seek Additional Information

• Byrd JW, Jones KS: Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: minimum three-year follow-up. Am J Sports Med 2002; 30: pp. 474-478.
• DaSilva MF, Williams JS, Fadale PD, et al.: Pediatric throwing injuries about the elbow. Am J Orthop 1998; 27: pp. 90-96.
• Lyons ML, Werner BC, Gluck JS, et al.: Osteochondral autograft plug transfer for treatment of osteochondritis dissecans of the capitellum in adolescent athletes. J Shoulder Elbow Surg 2015; 24: pp. 1098-1105.
• Peterson RK, Savoie FH, Field LD: Osteochondritis dissecans of the elbow. Instr Course Lect 1999; 48: pp. 393-398.
• Pill SG, Ganley TJ, Flynn JM, Gregg JR: Osteochondritis dissecans of the capitellum: arthroscopic-assisted treatment of large, full-thickness defects in young patients. Arthroscopy 2003; 19: pp. 222-225.
• Takahara M, Ogino T, Sasaki I, et al.: Long term outcome of osteochondritis dissecans of the humeral capitellum. Clin Orthop Relat Res 1999; 363: pp. 108-115.
• Woods GW, Tullos HS, King JW: The throwing arm: elbow joint injuries. J Sports Med 1973; 1: pp. 43-47.