Anisau, A

Mulier, E

Posadzy, MS

Vanhoenacker, Filip

Ghent University Academic Bibliography

Case 16265 Panner's diseaseA. Anisau , M.S. Posadzy , E. Mulier , F. M. Vanhoenacker .1, 2 3 1 1, 2, 41. General Hospital AZ Sint-Maarten Duffel-Mechelen, Liersesteenweg 435, B-2800 Mechelen,Belgium.2. University Ghent, Department of Medicine and Health Sciences.3. W. Dega Orthopaedic and Rehabilitation University Hospital of Karol Marcinkowski Universityof Medical Sciences Poznan, PL.4. University Hospital Antwerp, University Antwerp, Department of Radiology, University HospitalAntwerp; Wilrijkstraat, 10, 2650 Antwerp, Belgium. Email:filip.vanhoenacker@telenet.be University Hospital Antwerp  Musculoskeletal System Section: 2018, Dec. 5 Published: 7 year(s), malePatient:Clinical HistoryA 7-year old youth soccer player presented with periodic pain and slight swelling of his right elbowsince two months, without previous trauma. There was a limited range of motion in the elbow.Imaging FindingsConventional radiography showed joint effusion, irregular contours of the capitellum, increasedbone density and a thin radiolucent line in the subchondral bone (Figures 1a and 1b). Follow-upwith Cone Beam CT 2 months later depicted a crescent with vacuum phenomenon in thesubchondral bone (Figures 2a and 2b), corresponding to the radiolucent line seen on radiographs. Subsequent MRI revealed intact articular cartilage of the capitellum, predominantly low signal ofthe capitellum on both T1- and PD weighted images in keeping with sclerosis, and bone marrowedema in the adjacent humeral bone on FS PD weighted images (Figures 3a, 3b, 3c and 3d).DiscussionPanner's disease represents an osteochondrosis of the humeral capitellum. Osteochondroses affectepiphyses or epiphyseal equivalents and their progression ceases with skeletal maturity of theaffected part [1]. Panner's disease occurs most frequently in boys under the age of 11 [2, 3].Microtraumata from repetitive valgus stress and increased axial load are incriminated as the mainpathogenetic factors, typically occurring in throwing sports and gymnastics respectively [2]. This may lead to disruption of vessels that supply the nucleus of the capitellar ossification centre,leading to ischemia, resulting in disturbed endochondral ossification [2].Clinical presentation consists of pain, stiffness, swelling and a limited range of motion - especiallyan extension deficit, flexion deficit is less common [2]. The pain is activity-related [2].Conventional radiographs may show an irregular contour, sclerosis, subchondral radiolucency,fragmentation and flattening of the capitellum [2, 3].As the radiographical changes may be subtle, a low dose (Cone Beam) CT may be beneficialbecause of its greater sensitivity for detection of subtle changes and characterization of asubchondral vacuum phenomenon [4].The radiolucent subchondral crescent represents gas accumulation in a subchondral fissure, whichindicates osteonecrosis and impending articular collapse [4, 5]. This vacuum-phenomenondisappears when repair and re-ossification occurs [4].MRI shows heterogeneous signal intensity due to a variable degree of sclerosis, vacuumphenomenon and bone marrow edema in the ossified part of the capitellum, while the overlyingcartilage is normal [2, 4]. The vacuum phenomenon has a similar low signal as the sclerotic changesand is therefore difficult to detect on MRI.The majority of patients can be successfully treated conservatively, without serious morbidity [2].The differential diagnosis of Panner's disease consists of osteochondrosis dissecans (OCD), whichis seen in the second decade of life, when the ossification of the capitellum is complete [3, 5]. OCDaffects both bone and overlying cartilage and may be complicated by intra-articular loose bodyformation and has an overall poorer outcome [2, 3]. MRI may detect cartilage defects, therefore itwill be useful for distinguishing between Panner's disease and OCD. Our patient was treated conservatively, with rest, avoidance of weight bearing and of leaning uponthe right arm, promotion of passive movement and antiphlogistic medication. After six months therewas a significant clinical improvement and a partial regression of radiological abnormalities. Written informed patient consent for publication has been obtained.Final DiagnosisPanner's disease.Differential Diagnosis ListOsteochondrosis dissecans., Ossification variant of the capitellumFiguresFigure 1 Conventional radiograph of the right elbow, lateral and anteroposterior viewThe capitellum has a slightly irregular articular contour (white arrow) and there is aradiolucent crescent in the subchondral bone (black arrows). Note slight joint effusion withdisplacement of the elbow fad pads (white asterisks). © Image origin: Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium Area of Interest: Bones; Extremities; Musculoskeletal bone;  Imaging Technique: Conventional radiography;  Procedure: Diagnostic procedure;  Special Focus: Athletic injuries; The capitellum has a slightly irregular articular contour (white arrow) and there is aradiolucent crescent in the subchondral bone (black arrows). © Image origin: Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium Area of Interest: Bones; Extremities; Musculoskeletal bone;  Imaging Technique: Conventional radiography;  Procedure: Diagnostic procedure;  Special Focus: Athletic injuries; Figure 2 Cone Beam CT of the right elbowCoronal image:The capitellum has an increased density and is slightly irregularly delineated(white arrow). There is a subchondral crescent-shaped vacuum phenomenon (black arrow). © Image origin: Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium Area of Interest: Bones; Musculoskeletal bone; Musculoskeletal joint;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Athletic injuries; Sagittal image: The capitellum has an increased density and is slightly irregularly delineated(white arrow). There is a subchondral crescent-shaped vacuum phenomenon (black arrow). © Image origin: Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium Area of Interest: Bones; Musculoskeletal bone; Musculoskeletal joint;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Athletic injuries; Figure 3 MRI of the right elbow,T1 and FS PDCoronal T1-weighted image: the capitellum is of heterogeneous signal intensity with areas oflow signal anteriorly (white arrow). The overlying articular cartilage is intact (small whitearrowheads). © Image origin: Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium Area of Interest: Bones; Musculoskeletal bone; Musculoskeletal joint;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Athletic injuries; Sagittal T1-weighted images: the capitellum is of heterogeneous signal intensity with areasof low signal anteriorly and high signal posteriorly (white arrow). The overlying articularcartilage is intact (small white arrowheads). © Image origin: Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium Area of Interest: Bones; Musculoskeletal bone; Musculoskeletal joint;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Athletic injuries; Coronal FS PD images: the capitellum is of low signal (white arrow). The overlying cartilageis intact (white arrowheads). Note bone marrow edema in the distal humerus (black arrow). © Image origin: Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium Area of Interest: Bones; Musculoskeletal bone; Musculoskeletal joint;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Athletic injuries; Sagittal FS PD images: the capitellum is of low signal (white arrow). The overlying cartilageis intact (white arrowheads). Joint effusion (black asterisks). Note bone marrow edema in thedistal humerus (black arrow). © Image origin: Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium Area of Interest: Bones; Musculoskeletal bone; Musculoskeletal joint;  Imaging Technique: MR;  Procedure: Diagnostic procedure;  Special Focus: Athletic injuries; References[1] Danger F, Wasyliw C, Varich L (2018) Osteochondroses Semin Musculoskelet Radiol Vol. 22.[2] Claessen FM, Louwerens JK, Doornberg JN, van Dijk CN, Eygendaal D, Bekerom MP (2015)Panner's disease: literature review and treatment recommendations J Child Orthop 9(1): 9-17[3] Atanda Jr A, Shah SA, O'Brien K (2011) Osteochondrosis: common causes of pain in growingbones Am fam physician 83(3)[4] Anisau A, Posadzy M, Vanhoenacker F (2018) Panner's Disease: The Vacuum PhenomenonRevisited Journal of the Belgian Society of Radiology 102(1)[5] Resnick D (2002) Osteochondroses Diagnosis of Bone and Joint Disorders, 4th ed., Chapter 74.3686-3741CitationA. Anisau , M.S. Posadzy , E. Mulier , F. M. Vanhoenacker .1, 2 3 1 1, 2, 41. General Hospital AZ Sint-Maarten Duffel-Mechelen, Liersesteenweg 435, B-2800 Mechelen,Belgium.2. University Ghent, Department of Medicine and Health Sciences.3. W. Dega Orthopaedic and Rehabilitation University Hospital of Karol Marcinkowski Universityof Medical Sciences Poznan, PL.4. University Hospital Antwerp, University Antwerp, Department of Radiology, University HospitalAntwerp; Wilrijkstraat, 10, 2650 Antwerp, Belgium. Email:filip.vanhoenacker@telenet.be (2018,Dec. 5)  Panner's disease {Online}URL: http://www.eurorad.org/case.php?id=16265

Panner's disease

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