Br J Sp Med 1991; 25(3)
Bilateral osteochondritis dissecans of the elbowtreated by Herbert screw fixation
Goro Inoue MDNagoya University Branch Hospital, Nagoya, Japan
The case of a 15-year-old boy, a high-performancemotocross rider, who developed bilateral osteochondritisdissecans of the elbow is described. Both lesions weresuccessfully treated by Herbert screw internal fixation.
Keywords: Osteochondritis dissecans' elbow, motocross,Herbert screw
Osteochondritis dissecans of the elbow is an uncom-mon disorder and in one series it comprised only 6%of all patients with osteochondritis dissecans'. It mostcommonly affects the dominant arm of adolescentmales who are engaged in throwing sports such asbaseball. This lesion, however, has rarely beendescribed in other athletic activities. The purpose ofthis paper is to report a high-performance motocrossrider with bilateral lesions who was treated success-fully using Herbert screw internal fixation.
Case reportA 15-year-old boy presented with a 6-month historyof pain in both elbows during motorcycle activities.He trained for motocross for 3 years, spending 10-12hours/week practising. There was no past history ofsignificant direct trauma to his elbows. On clinicalexamination, he had tenderness over the radial headand capitellum with an effusion. The active range ofmovement of his elbow was 00 of extension to 1340 offlexion in the right, and -12° of extension to 1280 offlexion in the left. Radiological examination showedrarefaction with a sclerotic rim of the capitellumbilaterally (Figure 1).The right elbow was explored through a lateral
approach. There was a defect in the articular surfacewith a loose fragment in situ. The fragment wasalmost entirely articular cartilage of full thickness,measuring 1 x 2cm. The crater was curetted and
Address for correspondence: G. Inoue, Department ofOrthopaedic Surgery, Nagoya University Branch Hospital, 1-1-20Daikominami, Higashi-ku, Nagoya 461, Japan© 1991 Butterworth-Heinemann Ltd.0306-3674/91/030142-03
filled with iliac cancellous bone chips (Figure 2). Thefixation with a Herbert screw was performed afteradapting the fragment to its bed (Figure 3). Theoperative findings and procedure on the left elbowwere similar to that on the right. After surgery thepatient was placed in a posterior splint for 2 weeks,and then started on active exercises to develop hisrange of movement. Three months after surgery, hewas allowed to return to motocross riding. Two yearslater he had a full range of movement in both elbowswith no pain. His radiographs showed completereossification of the capitellar cyst and normallycontoured joint surfaces, with enlargement of theradial head bilaterally (Figure 4). He belonged to anorganized competitive motocross club and wasworking out on the motocross 20-30 h weekly,aiming at becoming a professional rider.
DiscussionAlthough the cause of osteochondritis dissecans ofthe elbow is unknown and is controversial, severalauthors suggest that excessive use may bring on thedisorder'13. Mitsunaga et al. reported that 38 of 57patients in his series were participating in one ormore sports activities at the onset of symptoms3, andthat the sports most commonly involved werebaseball (20), wrestling (14), and football (five); theother sports included tennis (three), basketball (two),golf (two), shotput (one) and gymnastics (one). Toour knowledge, there was no case report of thislesion in motorcyclists. It was postulated that thisinjury had a strong relationship to compressive forcesacross the radiocapitellar joint from repetitive loadingof the elbow.
In this case the arm often functioned as a shockabsorber under stress during motocross riding. Thisexposed the patient's developing radiocapitellarjoints to repetitive shear and compressive forces.
Various forms of treatment of osteochondritisdissecans have been used, including conservativetreatment" 4, removal of loose body with or withoutdrilling/curettage of the crater2' , simple excision ofthe fragment3, and fixation of the fragment with bone
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Figure 1. Preoperative radiographs of both elbows showing rarefaction surrounded by a zone of sclerosis of the capitellum
Figure 1. Preoperative radiographs of both elbows showing rarefaction surrounded by a zone of sclerosis of the capitellum
Figure 2. Intraoperative photograph showing the craterafter removal of the fragment
pegging5. A review of the literature indicated that theopinion is generally against early operative interven-tion. However, Mitsunaga et al. reported that theoutcome of the lesions still attached to the capitellumcould not be predetermined, and they found that42% progressed to become loose bodies3. If thesefragments were securely fixed in place, it is possiblethat they might survive and help to reconstitute a
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Figure 3. The fragment was fixed in situ using a Herbertscrew
better articular surface for the capitellum.The Herbert screw can be inserted through the
articular cartilage without causing undue damage. Itleaves no protruding head within the joint andprovides a rigid fixation for small osteochondralfragments; this allows early movement of the elbowjoint6. The result in this patient would suggest thatfurther clinical trials are needed.
Br J Sp Med 1991; 25(3) 143
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5 Oka Y, Imai N. Treatment of little league elbow. Jpn J OrthopSports Med 1987; 6: 223-36
6 Herbert TJ, Fisher WE. Management of the fractured scaphoidusing a new bone screw. J Bone Joint Surg [Br] 1984; 66B: 114-23
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