Osteochondritis dissecans

Osteochondritis dissecans and loose bodies

Osteochondritis dissecans of the Elbow (OCD) is the fragmentation and separation of a portion of the cartilage of the joint. This usually presents during adolescence. Symptoms are pain aggravated by motion, limited motion, clicking, and swelling.

It may be caused by injury, but not always. A history of significant trauma can be elicited in approximately 50% of patients. Males are more commonly affected with a ratio of 3:1. The osteochondral fragment may remain in situ, or be slightly displaced or become loose within the joint cavity. If the fragment remains attached to the underlying bone, healing can occur. If completely detached, complete healing does not occur. The loose cartilage body may increase in size and cause locking and clicking of the joint. In some cases, the fragment may become absorbed. Treatment of this lesion depends on the status of the fragment.

Osteochondritis dissecans (OCD) is a condition that develops in joints, most often in children and adolescents. It occurs when a small segment of bone begins to separate from its surrounding region due to a lack of blood supply. As a result, the small piece of bone and the cartilage covering it begin to crack and loosen.

The most common joints affected by osteochondritis dissecans are the knee, ankle and elbow, although it can also occur in other joints. The condition typically affects just one joint, however, some children can develop OCD in several joints.

In many cases of OCD in children, the affected bone and cartilage heal on their own, especially if a child is still growing. In grown children and young adults, OCD can have more severe effects. The OCD lesions have a greater chance of separating from the surrounding bone and cartilage, and can even detach and float around inside the joint. In these cases, surgery may be necessary.

Cause

It is not known exactly what causes the disruption to the blood supply and the resulting OCD. Doctors think it probably involves repetitive trauma or stresses to the bone over time.

Symptoms

Pain and swelling of a joint — often brought on by sports or physical activity — are the most common initial symptoms of OCD. Advanced cases of OCD may cause joint catching or locking.

Doctor Examination

After discussing your child’s symptoms and medical history, your doctor will perform a physical examination of the affected joint.

Other tests which may help your doctor confirm a diagnosis include:

X-rays. These imaging tests provide detailed pictures of dense structures, like bone. An x-ray of the affected joint is essential for an initial OCD diagnosis, and to evaluate the size and location of the OCD lesion.

Treatment

Observation and Activity Changes

In most cases, OCD lesions in children and young teens will heal on their own, especially when the body still has a great deal of growing to do. Resting and avoiding vigorous sports until symptoms resolve will often relieve pain and swelling.

Nonsurgical Treatment

If symptoms do not subside after a reasonable amount of time, your doctor may recommend the use of crutches, or splinting or casting the affected arm, leg or other joint for a short period of time.

In general, most children start to feel better over a 2- to 4-month course of rest and nonsurgical treatment. They usually return to all activities as symptoms improve.

Surgical Treatment

Your doctor may recommend surgery if:

  • Nonsurgical treatment fails to relieve pain and swelling
  • The lesion is separated or detached from the surrounding bone and cartilage, moving around within the joint
  • The lesion is very large (greater than 1 centimeter in diameter), especially in older teens

There are different surgical techniques for treating OCD, depending upon the individual case.

  • Drilling into the lesion to create pathways for new blood vessels to nourish the affected area. This will encourage healing of the surrounding bone.
  • Holding the lesion in place with internal fixation (such as pins and screws).
  • Replacing the damaged area with a new piece of bone and cartilage (called a graft). This can help regenerate healthy bone and cartilage in the area damaged by OCD.

In general, crutches are required for about 6 weeks after surgical treatment, followed by a 2- to 4-month course of physical therapy to regain strength and motion in the affected joint.

A gradual return to sports may be possible after about 4 to 5 months.

Loose Bodies

During repetitive overhead and lifting sports and occupations, the elbow experiences tremendous stress. This may lead to the formation of small loose fragments of cartilage or bone (loose bodies) or elbow joint spurs. This is more common in heavy manual workers and weightlifting athletes.
The loose bodies can cause pain, clicking or locking of your elbow. Your elbow may get ‘stuck’ and then click free (unlock). This is often painful. Sometimes you may feel something moving around inside your elbow joint and be aware of the loose body.
If stiffness and early morning discomfort is associated with this, then arthritis might be present. 

Painkillers and physiotherapy are often helpful, but if the symptoms are severe and debilitating, removal of the loose bodies by arthroscopy or open surgery is indicated. Arthroscopic removal is becoming the treatment of choice nowadays.