Panner's Disease: Difference between revisions

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<div class="editorbox">  '''Original Editor '''- [https://www.physio-pedia.com/User:Shreya_Pavaskar Shreya Pavaskar] <br>
<div class="editorbox">  '''Original Editor '''- [https://www.physio-pedia.com/User:Shreya_Pavaskar Shreya Pavaskar] <br>


  '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
  '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>


== Definition ==
Panner's disease is [[bone]] growth disorder (osteochondrosis) of the humeral capitellum ossification centre, at the lateral aspect of the [[elbow]]<ref name=":2">Nordlie H, Rognstad M, Iveland H. [https://tidsskriftet.no/en/2021/06/medisin-i-bilder/panners-disease Panner's disease.] Tidsskr Nor Laegeforen. 2021 Jun 24;141(10). English, Norwegian</ref>.


== Introduction ==
It is a rare disease, found most commonly in boys under 10 years old, and in a unilateral presentation<ref name=":0">Claessen FM, Louwerens JK, Doornberg JN, van Dijk CN, Eygendaal D, van den Bekerom MP. [https://pubmed.ncbi.nlm.nih.gov/25663360/ Panner's disease: literature review and treatment recommendations.] J Child Orthop. 2015 Feb;9(1):9-17.</ref>.
[[File:Elbow Joint.jpg|thumb]]Panner's disease is defined as an [[osteochondrosis]] of the humeral capitellum <ref>Schumacher R, Müller U, Schuster W. Rare localisation of osteochondrosis juvenilis (author's transl). Der Radiologe. 1981 Apr 1;21(4):165-74.</ref>. Patients aged 10 years and younger have lesions similar to those described by Dane Panner, without intra-articular loose bodies <ref>Ruch, DS , Poehling, GG . Arthroscopic treatment of Panner's disease. Clin Sports Med (1991); 10 (3): 629–636</ref>. It is believed that Panner's disease predominantly occurs in boys because of the delayed appearance and maturation of the secondary growth centres.<ref>Claessen FM, Louwerens JK, Doornberg JN, van Dijk CN, Eygendaal D, van den Bekerom MP. Panner’s disease: literature review and treatment recommendations. Journal of children's orthopaedics. 2015 Feb 1;9(1):9-17.</ref>
</div>


== Clinically Relevant Anatomy ==
== Clinically Relevant Anatomy ==
[[File:Elbow Illustration.jpg|thumb]]
The [[elbow]] joint is a synovial hinge joint. The three bones that make up the articulation of the joint are: the distal end of the [[humerus]] and proximal ends of the [[radius]] and [[ulna]]. The capitellum is the smooth, rounded lateral aspect of the distal articular surface of the humerus, which articulates with the head of the radius.<br>


The [[elbow]] joint is a synovial hinge joint. Three bones are involved in the articulation of the joint: the distal end of the humerus and proximal ends of the [[radius]] and [[ulna]]. The trochlea at the distal end of the [[humerus]], projects anteriorly and inferiorly at an angle of 45°. The trochlea notch at the proximal ulna, projects anteriorly and superiorly at an angle of 45°. The orientation of these articular surfaces allows a large amount of flexion. It achieves this by delaying contact between the humerus and ulna and providing space for musculature.
== Pathological Process ==


== Pathological Process ==
If the blood vessels suppyling the nuleus of the capitellum are disrupted, ischemia can occur,  leading to flatterning of the capitellum<ref name=":0" />. This could be due to:


Abnormal valgus stress after the age of 5 years is the most important factor in the development of Panner's disease. The capitellum has a rich vascular supply prior to the age of 5 years. Afterwards, the nucleus of the capitellum is mainly supplied by posterior vessels functioning as end arteries. If those vessels are disrupted by repetitive stress (i.e. throwing), ischaemia can develop. This may result in the disordered endochondral ossification called Panner's disease<ref>Claessen FM, Louwerens JK, Doornberg JN, van Dijk CN, Eygendaal D, van den Bekerom MP. Panner’s disease: literature review and treatment recommendations. Journal of children's orthopaedics. 2015 Feb 1;9(1):9-17.</ref>.  
* Repetitive valgus stress (e.g. throwing and catching).
* Increased axial loading<ref>Leahy I, Schorpion M, Ganley T. [https://pubmed.ncbi.nlm.nih.gov/25840494/ Common medial elbow injuries in the adolescent athlete]. J Hand Ther. 2015 Apr-Jun;28(2):201-10; quiz 211.</ref>.
* [[Trauma-Informed Care|Trauma]] to the elbow.<br>


== Clinical Presentation  ==
== Clinical Presentation  ==


* a history of several weeks of pain
* Lateral elbow pain, aggravted by activity and eased with rest<ref name=":1">John Hopkins Medicine. Panner's Disease. Available from: http://www.hopkinsallchildrens.org/Patients-Families/Health-Library/HealthDocNew/Panner-s-Disease (Accessed 14/10/2022)</ref>.
* stiffness in the elbow
* Elbow stiffness<ref name=":1" />.
* often with a history of [[Valgus Stress Test|valgus]] stress
* Reduced [[Range of Motion|range of motion]], especially into extension<ref name=":3">Anisau A, Posadzy M, Vanhoenacker F. [https://europepmc.org/article/MED/30483677 Panner's Disease: The Vacuum Phenomenon Revisited.] J Belg Soc Radiol. 2018 Oct 12;102(1):67</ref>.
* Aggravated with movement and relieved with rest
* Elbow [[Oedema Assessment|swelling]]<ref name=":1" />.<br>
* effusion and swelling
* Limited range of motion is typically observed with approximately 20° of extension loss and, less commonly, loss of flexion. The duration of symptoms varied from a few months to 2 years.
* The subchondral vacuum phenomenon is a rare finding, but is highly specific to this condition. The vacuum phenomenon, which represents subchondral gas formation, is a sign of bone ischaemia and may indicate aseptic [[necrosis]] <ref>Anisau A, Posadzy M, Vanhoenacker F. Panner’s disease: The vacuum phenomenon revisited. Journal of the Belgian Society of Radiology. 2018;102(1).</ref>


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


[[X-Rays|Plain radiographs]] were used for diagnosing Panner's disease.
The diagnosis is made on the clinical presentation and age of the patient, in combination with using [[X-Rays|radiographs]] and [[MRI Scans|magnetic resonance imaging]] (MRI's) to look for<ref>Sakata R, Fujioka H, Tomatsuri M, Kokubu T, Mifune Y, Inui A, Kurosaka M. [https://pubmed.ncbi.nlm.nih.gov/26628012/ Treatment and Diagnosis of Panner's Disease. A Report of Three Cases. Kobe J Med Sci.] 2015 Apr 22;61(2):E36-9.</ref><ref name=":3" /><ref name=":4">Chavda S, Abeid KA, Alhajri KK, Hasan NHA. [https://pubmed.ncbi.nlm.nih.gov/34790609/ Osteochondrosis of Humeral Capitellum, Diagnosis and Treatment - A Case Report.] J Orthop Case Rep. 2021 Jul;11(7):74-77.</ref>:


Initially the capitulum appears irregular with areas of radiolucency (indicating resorption), particularly adjacent to the articular surface, and sclerosis
* Joint [[Effusion tests|effusion]].
* Irregular delineation of the [[Joint line tenderness|joint line]].
* Radiolucency (indicating resorption), particularly adjacent to the articular surface.
* Sclerosis.
* Subchondral vacuum phenomenon.


    - in 3-5 months, radiographs show larger radiolucent areas followed by reconstruction of the bony epiphysis;
== Outcome Measures ==


    - in 1 to 2 years, the epiphysis returns to its normal configuration with no flattening, presumably because the elbow is not weight bearing joint
[[DASH Outcome Measure|DASH Outcome measure]]


    - in about 50% of patients, adjacent radial head shows early maturation compared with the uninvolved elbow
[[Visual Analogue Scale]]


A ''magnetic resonance imaging'' ([[MRI Scans|MRI]]) scan may show more detail. The MRI can give a better view of bone irregularities and can detect effusion.
== Management / Interventions  ==


== Outcome Measures  ==
Panner's disease can usually be managed with conservative treatment<ref name=":0" /> . The arm shoulder be rested, with stopping of aggravating activities, and [[Cryotherapy|ice]] can be used to ease pain and swelling<ref name=":1" />. Physiotherapy can help to [[Stretching|stretch]] and [[Strength Training|strengthen]] the elbow as indicated.


[[DASH Outcome Measure|DASH Outcome measure]]
{{#ev:youtube|g5E8oXQnjDU}}<ref>Overhead Athletics. Panner's Disease and Little Leaguer's Elbow Rehabilitation Exercise and Treatment. Available from:https://www.youtube.com/watch?v=g5E8oXQnjDU (Last accessed 14/10/2022)</ref>


== Management / Interventions ==
If these first line treatments do not improve the symptoms, the elbow can be immobilized/ [[Splinting|splinted]] for a short period<ref name=":4" />.  
[[File:Elbow brace.jpg|thumb]]
Symptomatic treatment for Panner's disease is sufficient because epiphysis becomes revascularized & develops normal configuration. Reducing elbow activities and avoiding straining activities can help with pain management and healing process. The use of a long arm splint for 3 to 4 weeks may be necessary until pain, swelling, and local tenderness subside. A cast was recommended for an inconsistent period of time ranging from 4 weeks to 11 months.<ref>Claessen FM, Louwerens JK, Doornberg JN, van Dijk CN, Eygendaal D, van den Bekerom MP. Panner’s disease: literature review and treatment recommendations. Journal of children's orthopaedics. 2015 Feb 1;9(1):9-17.</ref>Non-steroidal anti-inflammatory drugs  may be helpful.
 
It takes one to two years for the growth plate that makes up the capitellum to grow into solid bone. At this point, pain and symptoms usually go away completely. Treatments such as heat, [[cryotherapy]], and [[Ultrasound therapy|ultrasound]] may be used to ease pain and swelling.<br>


Usually after a period of recovery, the patient can return to their [[Sport Injury Epidemiology|sport]]. <br>
== Differential Diagnosis ==
== Differential Diagnosis ==


[[Osteochondritis Dissecans|Osteochondritis dissecans]]  
* The most common differential diagnosis is [[Osteochondritis Dissecans|osteochondritis dissecans]]<ref name=":2" />[[Osteochondritis Dissecans|.]]
* Lateral epicondylitis<ref>Kotnis NA, Chiavaras MM, Harish S. [https://pubmed.ncbi.nlm.nih.gov/22205505/ Lateral epicondylitis and beyond: imaging of lateral elbow pain with clinical-radiologic correlation.] Skeletal Radiol. 2012 Apr;41(4):369-86.</ref>.


== Resources ==
== Resources ==


[https://journals.sagepub.com/doi/10.1007/s11832-015-0635-2 Panner's disease: Literature review and treatment recommendations]
{{#ev:youtube|3W51jPKXTJ8}}<ref>Dr Nabil Ebraheim. Panner's Disease - Everything You Need To Know. Available from: https://www.youtube.com/watch?v=3W51jPKXTJ8 (Last accessed 14/10/2022)</ref>


== References ==
== References ==


<references />
<references />
[[Category:Elbow]]
[[Category:Paediatrics]]
[[Category:Conditions]]

Latest revision as of 13:33, 14 October 2022

Original Editor - Shreya Pavaskar
Top Contributors - Chloe Waller, Shreya Pavaskar and Vidya Acharya

Definition[edit | edit source]

Panner's disease is bone growth disorder (osteochondrosis) of the humeral capitellum ossification centre, at the lateral aspect of the elbow[1].

It is a rare disease, found most commonly in boys under 10 years old, and in a unilateral presentation[2].

Clinically Relevant Anatomy[edit | edit source]

Elbow Illustration.jpg

The elbow joint is a synovial hinge joint. The three bones that make up the articulation of the joint are: the distal end of the humerus and proximal ends of the radius and ulna. The capitellum is the smooth, rounded lateral aspect of the distal articular surface of the humerus, which articulates with the head of the radius.

Pathological Process[edit | edit source]

If the blood vessels suppyling the nuleus of the capitellum are disrupted, ischemia can occur, leading to flatterning of the capitellum[2]. This could be due to:

  • Repetitive valgus stress (e.g. throwing and catching).
  • Increased axial loading[3].
  • Trauma to the elbow.

Clinical Presentation[edit | edit source]

Diagnostic Procedures[edit | edit source]

The diagnosis is made on the clinical presentation and age of the patient, in combination with using radiographs and magnetic resonance imaging (MRI's) to look for[6][5][7]:

  • Joint effusion.
  • Irregular delineation of the joint line.
  • Radiolucency (indicating resorption), particularly adjacent to the articular surface.
  • Sclerosis.
  • Subchondral vacuum phenomenon.

Outcome Measures[edit | edit source]

DASH Outcome measure

Visual Analogue Scale

Management / Interventions[edit | edit source]

Panner's disease can usually be managed with conservative treatment[2] . The arm shoulder be rested, with stopping of aggravating activities, and ice can be used to ease pain and swelling[4]. Physiotherapy can help to stretch and strengthen the elbow as indicated.

[8]

If these first line treatments do not improve the symptoms, the elbow can be immobilized/ splinted for a short period[7].

Usually after a period of recovery, the patient can return to their sport.

Differential Diagnosis[edit | edit source]

Resources[edit | edit source]

[10]

References[edit | edit source]

  1. ↑ 1.0 1.1 Nordlie H, Rognstad M, Iveland H. Panner's disease. Tidsskr Nor Laegeforen. 2021 Jun 24;141(10). English, Norwegian
  2. ↑ 2.0 2.1 2.2 Claessen FM, Louwerens JK, Doornberg JN, van Dijk CN, Eygendaal D, van den Bekerom MP. Panner's disease: literature review and treatment recommendations. J Child Orthop. 2015 Feb;9(1):9-17.
  3. ↑ Leahy I, Schorpion M, Ganley T. Common medial elbow injuries in the adolescent athlete. J Hand Ther. 2015 Apr-Jun;28(2):201-10; quiz 211.
  4. ↑ 4.0 4.1 4.2 4.3 John Hopkins Medicine. Panner's Disease. Available from: http://www.hopkinsallchildrens.org/Patients-Families/Health-Library/HealthDocNew/Panner-s-Disease (Accessed 14/10/2022)
  5. ↑ 5.0 5.1 Anisau A, Posadzy M, Vanhoenacker F. Panner's Disease: The Vacuum Phenomenon Revisited. J Belg Soc Radiol. 2018 Oct 12;102(1):67
  6. ↑ Sakata R, Fujioka H, Tomatsuri M, Kokubu T, Mifune Y, Inui A, Kurosaka M. Treatment and Diagnosis of Panner's Disease. A Report of Three Cases. Kobe J Med Sci. 2015 Apr 22;61(2):E36-9.
  7. ↑ 7.0 7.1 Chavda S, Abeid KA, Alhajri KK, Hasan NHA. Osteochondrosis of Humeral Capitellum, Diagnosis and Treatment - A Case Report. J Orthop Case Rep. 2021 Jul;11(7):74-77.
  8. ↑ Overhead Athletics. Panner's Disease and Little Leaguer's Elbow Rehabilitation Exercise and Treatment. Available from:https://www.youtube.com/watch?v=g5E8oXQnjDU (Last accessed 14/10/2022)
  9. ↑ Kotnis NA, Chiavaras MM, Harish S. Lateral epicondylitis and beyond: imaging of lateral elbow pain with clinical-radiologic correlation. Skeletal Radiol. 2012 Apr;41(4):369-86.
  10. ↑ Dr Nabil Ebraheim. Panner's Disease - Everything You Need To Know. Available from: https://www.youtube.com/watch?v=3W51jPKXTJ8 (Last accessed 14/10/2022)
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