THE CLINICAL SYNDROME

• In spite of the fact that osteochondritis dissecans was not for the first time described until the late 1800s, its precise cause is still unknown.

• According to the predominant school of thought, osteochondritis dissecans develops as a consequence of repetitive microtrauma to the articular cartilage of the elbow.

• According to studies, the characteristic localized separation of the articular cartilage and the subchondral bone is caused by repetitive microtrauma that results in an ischemic insult to the cartilage and supporting structures.

• The elbow of the dominant upper extremity is the part of the body that is most frequently affected by osteochondritis dissecans in young male athletes.

• Bilateral findings occur in approximately 5 percent of those who are affected.

• Racquetball, baseball, weight lifting, cheerleading, and competitive gymnastics are the sports that have been linked to the development of osteochondritis dissecans the most frequently.

• Patients suffering from osteochondritis dissecans will invariably experience pain when using the affected elbow, which improves when the elbow is allowed to rest.

• The pain is typically intense, constant, and difficult to localize.

• The bodies of the joints frequently become loose. There have been reports of disease on both sides.

SIGNS AND SYMPTOMS

• Pain is typically the first symptom that a patient experiences when they have osteochondritis dissecans, which is an elbow condition.

• The patient has trouble localizing the pain, as evidenced by the fact that they frequently rub their elbow when attempting to describe it.

• When joint mice are present, the patient may experience grating or popping sensations when bending and straightening the elbow that is affected by the condition.

• It is common to experience problems sleeping.

• Patients who suffer from osteochondritis dissecans may experience a reduction in their ability to fully extend the elbow that is affected by the condition.

• Active compression across the radiocapitellar joint caused by muscular forces and an active radiocapitellar compression test both have the potential to reproduce the patient's pain.

• An active radiocapitellar compression test is carried out by instructing the patient to pronate and supinate the forearm while simultaneously flexing and extending the elbow.

• During the physical examination, the patient may also report that the elbow is tender to palpation. In the event that the patient has sustained an associated acute injury to the elbow, the patient may exhibit symptoms such as swelling and ecchymosis.

• The inability to fully extend the elbow is the direct consequence of flexion contracture, which may also be present.

TESTING

• Plain radiographs need to be taken of every patient who comes in complaining of elbow pain in order to rule out joint mice and other hidden bony disorders like avulsion fractures of the olecranon.

• Due to the clinical presentation of the patient, it is possible that additional testing is required.

• These tests could include a complete blood count, uric acid level, erythrocyte sedimentation rate, and testing for antinuclear antibodies.

• If joint instability is suspected or if symptoms of osteochondritis dissecans continue to manifest themselves, a magnetic resonance imaging (MRI) exam of the elbow is recommended.

• In order to diagnose entrapment neuropathy at the elbow and rule out cervical radiculopathy, electromyography, also known as an EMG, is typically performed.

• The injection technique that will be described later can be utilized both as a diagnostic tool and a treatment strategy.

DIFFERENTIAL DIAGNOSIS

• Cervical radiculopathy can occasionally be mistaken for osteochondritis dissecans; however, patients who suffer from cervical radiculopathy typically experience pain in the neck and in the proximal upper extremity in addition to symptoms that occur below the elbow.

• As was mentioned earlier, EMG is able to differentiate between osteochondritis dissecans and radiculopathy.

• Bursitis, arthritis, tendinitis, and gout are some other conditions that can appear similarly to osteochondritis dissecans and lead to diagnostic confusion.

• It is possible for the olecranon bursa, which is located in the posterior aspect of the elbow joint, to become inflamed as a result of direct trauma to the joint or from excessive use of the joint.

• Bursae in the antecubital and cubital regions, in addition to those located between the insertion of the biceps and the head of the radius, can also become inflamed and develop bursitis if they are not properly maintained.

TREATMENT

• When administering an injection for osteochondritis dissecans, the patient is first positioned in the supine position with the affected arm fully adducted at the patient's side, the elbow fully extended, and the dorsum of the hand resting on a folded towel to relax the affected tendons.

• Only then is the injection administered.

• A sterile syringe with a capacity of 5 milliliters is used to draw up a total of 1 milliliter of local anesthetic and 40 milligrams of methylprednisolone.

• The medial epicondyle is located after the sterile preparation of the skin that lies over the medial aspect of the joint.

• A needle measuring 1 inch in length and 25 gauges in diameter is inserted through the patient's skin, perpendicular to the medial epicondyle, and into the subcutaneous tissue that lies over the affected tendon.

• This procedure is performed in accordance with strict aseptic technique.

• If bone is found, the needle is retracted into the subcutaneous tissue and the procedure is repeated.

  • After that, a gentle injection of the contents of the syringe is performed.

• It ought to feel like there is very little resistance being injected.

• If there is a significant amount of resistance, the needle is most likely already embedded in the tendon; in this case, the injection needs to be stopped until there is significantly less resistance.

• After the needle has been removed, a sterile pressure dressing and an ice pack are applied to the area that was just given the injection.

COMPLICATIONS AND PITFALLS

• If an inflamed tendon that has already been damaged is injected directly, this technique can cause the tendon to rupture due to the associated trauma.

  • This is one of the most significant risks associated with this injection method.

• Therefore, before the clinician continues with the injection, they should make sure that the needle position is confirmed to be outside of the tendon.

• Infection is yet another potential risk associated with the injection method; however, this should be an extremely remote possibility if the aseptic technique is strictly adhered to.

• It is possible to avoid injury during injection by paying close attention to the anatomical features that are clinically significant; in particular, the ulnar nerve is vulnerable to injury at the elbow.

• After receiving this type of injection, approximately one quarter of patients experience an increase in the pain for a brief period of time.

• Patients should be informed that this is a possibility.