Acute Phase
Rehabilitation program
Occupational therapy
In patients with intact humeral capitellum osteochondritis dissecans lesions that are a cause of significant pain, the primary focus should be limitation of activity, rest, application of ice, and adequate pain control. [22] Consider placing the patient in a sling for pain relief only. If pain persists, occupational therapy for splinting/casting may be indicated; however, prolonged splinting or casting is not usually necessary and may increase the risk of a flexion contracture. The use of modalities such as ice may also be beneficial for pain relief.
Related Medscape topics:
Resource CenterOptimizing the Use of Patient Data to Improve Outcomes for Patients: Narcotics for Chronic Noncancer Pain
Resource CenterPain Management: Pharmacologic Approaches
Surgical intervention
Surgical intervention is indicated in cases of progressive joint contracture, failed conservative treatment, partially attached or completely detached fragments, or locking and catching of the joint with extension and/or flexion.
Arthroscopy for excision of the loose body and abrasion chondroplasty is preferred, with conversion to an open procedure if necessary. Surgical fixation of the loose body may be attempted.
Radial head excision is recommended in older patients who have a radial head deformity, radiocapitellar degenerative changes, or limitation of forearm rotation. Anterior capsule release may help to relieve flexion contractures.
Arai et al developed an arthroscopic-assisted drilling method for humeral capitellum osteochondritis dissecans lesions. [23] The method involves drilling through the radius in a distal-to-proximal direction with the use of a single 1.8-mm Kirschner (K)-wire that is "inserted from the shaft of the radius approximately 3 cm distal to the humeroradial joint into the joint" as well as with the guidance of arthroscopy.
The forearms were supinated with the tip of the K-wire at the lateral side of the lesion. Drilling was performed at 30º elbow flexion, which was to 60º to 90º to 120º while maintaining supination, to drill in 4 sites (1 site for each angle of flexion) of the lateral side of the lesion. Then, the forearm was moved from supination to pronation so that the tip of the K-wire was placed in the medial side of the lesion in the humeral capitellum, and as with the lateral side, drilling was performed in 4 sites. The investigators noted that the procedure allows the entire lesion to be drilled, is minimally invasive, and may allow the athlete to return to sports earlier. [23]
Nobuta et al evaluated the efficacy of fragment fixation in 28 cases of humeral capitellum osteochondritis dissecans. The investigators noted that post surgery, 25 patients reported no pain and 3 reported decreased pain. The average arc of flexion improved 16º compared with the pre-operative arc, and "radiographic findings showed complete healing of the lesion in 11 patients, partial healing in 12, unchanged in 3, and loose body formation in 2." [24]
The ratio of complete or partial healing of the lesion appeared to be related to the preoperative radiographic findings of the lesion's thickness. In 16 patients in whom the thickness of the lesion was less than 9 mm on preoperative radiograph, there was 100% complete or partial healing, whereas it was 58% in 12 patients in whom the lesion thickness was 9 mm or more. Thus, Nobuta et al observed that fragment fixation is effective when humeral capitellum osteochondritis dissecans lesions are less than 9 mm thick, and "fixation by flexible wire or thread and revascularization by drilling for the fragment" are likely insufficient for large lesions with a thickness of 9 mm or more. [24]
Takahara et al evaluated the outcomes and determined the most useful classification the treatment of choice for humeral capitellum osteochondritis dissecans lesions. [13, 14] The investigators classified the lesions as stable or unstable. The findings at the initial presentation appeared to be useful in determining whether conservative (elbow rest) or surgical treatment would provide a better outcome for certain lesions.
Takahara et al concluded that at the time of the initial presentation stable humeral capitellum osteochondritis dissecans lesions that healed completely with elbow rest had: (1) an open capitellar growth plate, (2) localized flattening or radiolucency of the subchondral bone, and (3) good elbow motion. However, unstable lesions, for which surgery provided significantly better results, had 1 of the following: (1) a capitellum with a closed growth plate, (2) fragmentation, or (3) restriction of elbow motion of ≥ 20º. Furthermore, for "large unstable lesions, fragment fixation or reconstruction of the articular surface" led to better results than simple excision. [13, 14]
Recovery Phase
Rehabilitation program
Occupational therapy
Begin with passive ROM exercises, followed by active ROM exercises to prevent contractures. As the patient gets stronger and can tolerate more activity, proceed with progressive resistive exercises. Electrical stimulation may also facilitate recovery, although this has not been proven in clinical trials.
Medical issues/complications
Restrict activity for 6-8 weeks after symptom resolution.
Maintenance Phase
Rehabilitation program
Occupational therapy
Continue with ROM and strengthening exercises for the elbow. Take measures to protect the elbow from further injury. Advise patients of the importance of a shoulder program as well as a wrist/finger program. These programs should also focus on ROM and strengthening exercises.
Medical issues/complications
Return to activity is gradual. Full activity may be resumed at 6 months with complete symptom resolution. Follow-up radiography to assess healing is recommended before a return to full activity. Immediate cessation of activities and reevaluation is warranted if symptoms recur.
