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Panner’s Disease / Osteochondrosis

- Discussion:
    - disease involving capitulum of distal humerus that produced changes similar to those observed in Legg Calve Perthes disease;
          - it should be distinguished from osteochondritis dissecans (which occurs in the older child or adolescent - older than age 13 years);
    - pathologic process is believed to be caused by an interferrence in blood supply to growing epiphysis, which results in resorption & eventual repair
          and replacement of the ossification center;
          - in patients under 20 years of age, capitellum is only supplied by end arteries entering posteriorly;
    - Panner's disease almost always occurs in the dominant elbow in boys between 5 and 12 years of age;
    - inciting causes:
          - chronic repetitive trauma, congenital and hereditary factors, embolism (fat), and endocrine disturbances;

- Diff Dx:
    - Panner's disease should not be confused w/ more common osteochondritis dessicans of capitulum seen in adolescent boys, which is related to throwing activities;
    - throwing injuries:
          - although initial x-ray appearance of two conditions may be similar, the progression of the changes differs;

- Clinical manifestations:
    - patients report intermittent pain and stiffness in the affected elbow that lasts for several months;
    - symptoms are relieved by rest and aggravated by activity;
    - on PE local tenderness over capitulum, slight effusion, & synovial thicknening of the elbow joint are found;
    - limited extension is typical, lacking 20 to 30 deg of full extension;
    - there may be slight loss of pronation and supination w/ tenderness;

- Radiographic changes:
    - radiology of pediatric elbow
    - initially the capitulum appears irregular with areas of radioluceny (indicating resorption), particularly adjacent to
         the articular surface, and sclerosis;
    - in 3-5 months, radiographs show larger radiolucent areas followed by reconstruction of the bony epiphysis;
    - in 1 to 2 years, the epiphysis returns to its normal configuration w/ no flattening, presumably becausethe elbow is not wt bearing joint;
    - in about 50% of pts, adjacent radial head shows early maturation compared with the univolved elbow;

- Treatment:
    - symptomatic treatment for Panner's disease is sufficient because epiphysis becomes revascularized & develops normal configuration;
    - reducing elbow activities, particularly those that strain the joint, usually relieves pain and allows gradual return of elbow motion;
         - however, the use of a long arm cast or splint for 3 to 4 weeks may be necessary until pain, swelling, and local tenderness subside;
    - long term outlook is execellent, but a slight loss of elbow extension may persist in some patients;
    - of note, as with Perthes disease, the radiographic reovery may lag behind  the clinical resolution of symptoms

Arthroscopic Treatment of Panner's Disease.