Rationale

Nonoperative management is considered the first step in the treatment of patients with a clinically and radiographically stable OCD lesion of the humeral capitellum; however, studies suggest differences in outcomes and healing related to skeletal maturity of the capitellum.

Clinical comment

Although nonoperative management is commonly the first step in the treatment of many osteochondral injuries, not all patients are appropriate candidates for nonoperative treatment. It is important to understand and identify which patients can be considered good candidates for nonsurgical management and which patients have a higher likelihood of needing surgical treatment.

Available literature and quality of the evidence

• The literature reviewed and summarized to address the clinical question above includes level III retrospective cohort studies and level IV case series studies.

Findings

Early studies on nonoperative management of elbow OCD lesions reported generally poor outcomes.¹–³ Takahara et al. reported 50% of patients had residual symptoms in their elbow with daily activity and displayed radiographic evidence of degenerative changes, and no patients returned to previous sport.² In subsequent studies, outcomes with nonoperative treatment have been stratified by radiographic and clinical findings at presentation.⁴,⁵ Takahara et al. and Mihara et al. characterized a lesion as “stable” if patients had an open capitellar physis, flattening or radiolucency of the subchondral bone, and normal elbow range of motion.⁴,⁵ A radiographically “early” defect was considered grade I (localized flattening or radiolucency without sclerosis) or grade II (nondisplaced fragment with sclerosis). A radiographically “advanced” defect showed grade III (displaced or detached fragment) changes.⁴,⁵ Early stable lesions in skeletally immature patients often heal with nonoperative management;⁴,⁵ therefore, a trial of nonoperative management was indicated in these patients. Nonoperative treatment typically included activity restriction, a brief period of immobilization, oral nonsteroidal anti‐inflammatory drugs (NSAIDs), and physical therapy exercises.⁴–⁶ Currently, no universal guidelines exist on duration of nonoperative treatment, but rather it is guided by symptoms. Generally, it involves six weeks of strict rest from activities that cause pain, with a gradual return to activity and sport over a three‐ to six‐month period.⁶,⁷

While patients with early stable lesions often healed with rest alone, more advanced defects and defects in patients with a closed capitellar physis are at higher risk of failure with nonsurgical treatment.⁴,⁵ In general, patients with a closed physis typically have more advanced OCD lesions at presentation.⁵ Mihara et al. reported significantly higher healing rates after nonoperative management in patients with early‐stage OCD lesions and an open physis when compared to patients with a more advanced OCD and a closed physis. They were unable to demonstrate a statistical difference in healing rates between early‐stage OCD lesions between patients with open versus closed physes, but the number of patients was small.⁵ In other reports, the healing rate with nonoperative management in patients with closed growth plates and unstable, advanced lesions has been low.³,⁵,⁶,⁸,⁹ Therefore, patients with an open capitellar physis and stable OCD lesions have greater healing potential with nonoperative management than patients with advanced OCD lesions with a closed physis.

Resolution of clinical scenario

• Outcomes of nonoperative management in patients with capitellar OCD lesions depend on the combination of the skeletal maturity of the capitellar physis, the radiographic grading of the defect, and the clinical stability of the defect.
  
• Better outcomes after nonoperative management are seen in patients with early lesions with open capitellar growth plates, localized flattening or radiolucency of the subchondral bone, and good elbow range of motion.
  
• Poor outcomes after nonoperative management are seen in patients with unstable, radiographically advanced lesions, and a closed capitellar physis.

Rationale

There have been several surgical treatments (i.e. fixation, debridement) described for unstable OCD lesions in the elbow. Debridement of the defect has shown good short‐term results, but larger defects may not do as well with debridement.

Clinical comment

Studies suggest that lesion stability, size, and location are important factors to consider when selecting the most appropriate form of treatment. Debridement procedures are a commonly considered treatment in patients with small, unstable OCD lesions, and in patients with stable lesions who have failed a nonoperative therapy. With advances in arthroscopic technique, debridement has become a mainstay of treatment in patients with unstable lesions and those refractory to nonoperative management.

Available literature and quality of the evidence

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