A fourteen year old male player presented with an insidious onset of pain in his dominant right elbow. He described pain with any weight bearing activities through his elbow and with throw-ins. He had also noticed that he had not been able to fully extend his elbow and that it felt weak.
On examination he had lost the final 10 degrees of elbow extension and had flexion that was limited to 100 degrees. There was some modest tenderness about the lateral elbow.
An x-ray series of the elbow demonstrates an effusion appears and a relatively large lucent area within the capitellum. Subsequent MR imaging shows that there is a 15 mm osteochondral lesion at the lateral capitellum with separation of a bony fragment that is approximately 13 x 11 x 6 mm in depth. The fragment has undergone extensive cystic change with loss of bone stock and is poorly defined on MR with moderate bone oedema. Intermediate to high T2 signal undercuts the fragment, with a component of fluid suspected on sagittal images suggesting lesion instability. A subsequent CT scan further demonstrates the lesion and defect in the subarticular bone and shows significant cystic changes and sclerosis at the margins.
This young player elected to pursue surgical treatment and underwent an arthroscopy. During this procedure the surgeon removed several loose bodies and the unstable osteochondral fracture from capitellum. This was followed by microfracture of the capitellum. Following surgery he was immobilised in a backslab for one week. At one week post-op the backslab was removed. He was noted to have almost full extension and flexion to 120 degrees. He was encouraged to work on his elbow ROM and returned to gym-based rehabilitation at three weeks post-op. At a seven week post-operative follow-up appointment he has a full range of motion, had no tenderness about his elbow and reported that his elbow “felt normal”. At this point he returned to running and skills training. At three months post-op he was cleared to return to normal football training.
Osteochondral lesions (at the elbow) generally involve the capitellum, but can occur in other areas. They are most commonly seen in male athletes who are aged between 12 and 15 years, a time when the capitellar epiphysis is almost completely fused. The dominant arm is most frequently affected. The most common sports which these patients participate are baseball, racquet sports, gymnastics, and weightlifting. Each of these sports involve repeated loading of the elbow. Given that it is primarily a running-based sport, this pathology is relatively rare among football players. In most cases it is likely that they are caused by a combination of repetitive trauma and a tenuous blood supply to the capitellum. Genetic factors and biomechanical differences in the articular cartilage of the capitellum and radial head may also be important. Pain is the primary symptom at presentation. As this case illustrates, the onset of pain is insidious and progressive and tends to be related to activity. The most common examination finding is a loss of elbow movement, most often extension.
Nonoperative treatment may be considered in cases where there is a stable lesion without any mechanical symptoms. It is estimated that with activity modification and avoidance of pain-provoking activities, approximately 50% of these osteochondral lesions can heal with this regime. Surgical intervention should be considered when patients do not respond to nonoperative treatment and for patients with unstable and non-viable lesions at presentation. There are a range of surgical techniques that could be considered. These include direct fixation, debridement of the fragment with drilling or microfracture of the underlying subchondral bone or the use of an osteochondral graft.
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