13-year-old female patient complained of pain, discomfort and spontaneous locking of the left elbow. She does gymnastics. There was no history of acute trauma.
X-ray examination of the left elbow: a lucent zone in the capitulum humeri demarcated by an osteosclerotic rim.
MR findings: there is a lesion that involves both the cartilage and bone marrow of capitulum humeri. The osteochondral lesion is localized in the anterior and lateral part of capitulum humeri. On STIR images the lesion looks filled with fluid and there are underlying cysts. On the STIR images there are minimal bone marrow oedema changes around the osteochondral lesion as well as in the caput radii. The other structures, including caput radii, are intact. The osteochondral lesion can be classified as unstable. There is a joint effusion both anteriorly and posteriorly regarding the distal humerus. There are intraarticular fragments localized in the joint effusion – posterior to the distal humerus (olecranon fossa) (Figure 2c). These fragments are proven on subsequent arthroscopy.
Osteochondral lesion (OCL) of the elbow can affect different structures of the joint, but is most frequent in the anterolateral part of capitulum humeri [1]. Factors such as repetitive trauma and valgus stress in the elbow are believed to be a cause for OCL of the elbow, though the exact aetiology is not clear [2]. Immature athletes, older than 10 years, are usually affected [3, 4].
Osteochondrosis of capitulum humeri is another disorder that affects immature skeleton and is known as Panner disease [5], which may develop spontaneously or as a result of trauma or overuse injury [6]. Patients are usually younger than 10 years [5, 7].
X-ray imaging features that may be used in distinguishing the two conditions include:
•for OCL of capitulum humeri - lucent area, sometimes surrounded by osteosclerotic rim. The articular surface is irregular. With progressive disease loose bodies may appear [7, 8]. There is a classification based upon these X-ray changes: grade I – lucent zone, grade II – demarcated zone or detachment between the bone lesion and the humerus, grade III – loose bodies [8].
•for Panner disease - reduction in size, increased opacity and fissures in the capitulum humeri during follow-up [7, 6].
MRI can be used for grading of osteochondral lesions as well as for classifying them as stable and unstable lesions. On T1-weighted images both stable and unstable lesions are characterized by a low or low-intermediate signal intensity [9]. The lack of fluid between the osteochondral fragment and the bone is a sign of stable lesion [10]. An OCL on MRI can be classified as unstable according to the following changes in T2 weighted sequences: hyperintense linear zone between the lesion and the adjacent bone, sublesional cyst, hyperintense linear zone that involves both the cartilage and the subchondral bone and focal articular surface defect [9]. These criteria are accepted for OCL of talar dome and femoral condyle and are used in OCL of capitulum humeri [8, 9].
Panner disease is a self-limiting disease and usually resolves spontaneously [5]. OCL can be treated conservatively or surgically, based upon clinical and radiological findings [8, 7].
Besides Panner’s disease, there are other conditions that should be taken into consideration in a more detailed differential diagnosis. Pseudodefect in capitulum humeri region is a normal variant and represents an anatomical sulcus located posteriorly [7]. Valgus impaction fracture, posterior dislocation of humerus and capitulum fracture can produce changes in capitulum humeri, but they can be distinguished by additional posttraumatic changes on the MRI [10].
Osteochondral lesion of capitulum humeri
From the provided X-ray and MRI images of the left elbow joint, the following can be observed:
• In the region of the humeral capitellum, the local contour appears slightly irregular, with a localized area of brightness (low-density shadow/radiolucent area), suggesting a possible subchondral lesion or bony changes.
• On the T2-weighted MRI, a high-signal band is observed beneath the articular cartilage surface of the humeral capitellum, and irregular signals can be seen locally on the articular surface, indicating potential damage to the subchondral region and the articular surface integrity.
• The joint space is basically normal, with no obvious signs of acute fracture lines or dislocation.
• No significant extensive soft tissue swelling or effusion is observed, but there may be slight edema around the subchondral lesion.
In summary, based on the clinical symptoms (pain, restricted movement, joint clicking or locking) and the imaging findings, OCL (Osteochondral Lesion of the Capitellum) and Panner’s disease are the main differential diagnoses to be considered.
Given the patient’s age (over 10 years old), involvement in gymnastics with repetitive loading, and localized osteochondral injury signs in the humeral capitellum, the most likely diagnosis is Osteochondral Lesion of the Capitellum (OCL). Panner’s disease typically occurs in children under 10, so it is not the primary consideration in this case. If necessary, further evaluation with dynamic ultrasound or contrast-enhanced MRI can be performed to assess the stability of the cartilage injury.
Treatment Strategies:
1. Conservative Treatment: Suitable for mild symptoms, stable lesions, or early-stage injuries. It is recommended to reduce or temporarily cease activities that repeatedly load the elbow joint. Non-steroidal anti-inflammatory drugs (NSAIDs) or physical therapy (hot compress, ultrasound, physiotherapy devices, etc.) may be used to relieve pain and inflammation.
2. Surgical Treatment: If there is a loose body, unstable lesion, or poor response to conservative treatment, surgical intervention may be considered, such as arthroscopic debridement or cartilage repair, depending on the extent of cartilage damage.
Rehabilitation and Exercise Prescription:
During symptom stabilization or postoperative rehabilitation, a gradual approach should be followed. The FITT-VP principle (Frequency, Intensity, Time, Type, Progression, Volume) may be used to design the exercise prescription:
• Early Stage (initial pain relief phase):
This report is based on available imaging and clinical information and is provided for reference only. It cannot replace in-person consultation or professional medical advice. Specific treatment plans require a comprehensive assessment by a specialist, taking the patient’s actual condition into account.
Osteochondral lesion of capitulum humeri
