Elbow under pressure: Radiological diagnosis of panner’s lesion

INTRODUCTION

Panner’s disease is an idiopathic osteochondrosis of the ossification center of the humeral capitellum. It is most commonly reported in boys aged 5–10 years and is associated with repetitive valgus stress and transient ischemia of the developing epiphysis. Although self-limiting, it may mimic other elbow disorders when seen at older ages, particularly osteochondritis dissecans (OCD). Accurate radiologic diagnosis is crucial to prevent unnecessary interventions.^[1] We present the radiographic and ultrasonographic findings of Panner’s disease in a 14-year-old cricketer, discuss its differentiation from OCD, and highlight the adjunctive role of magnetic resonance imaging (MRI).

CASE REPORT

A 14-year-old right-handed male cricket bowler presented with a 3-week history of progressive pain over the lateral aspect of the right elbow and limitation of terminal extension. There was no history of trauma, fever, or systemic illness. On examination, there was localized tenderness at the lateral condyle; extension was limited by approximately 15°, while flexion and rotations were preserved.

Frontal radiography of the right elbow [Figure 1] demonstrated an irregular, fragmented capitellar ossification center with mild subchondral sclerosis and preserved joint alignment. No metaphyseal fracture line or physeal widening was evident.

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Figure 1:

Frontal radiograph of the right elbow showing flattening, fragmentation, and subchondral sclerosis of the capitellum (arrow).

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High-resolution ultrasonography was performed with a 10–15 MHz linear transducer. The contralateral (left) elbow appeared normal with a smooth cortical outline [Figure 2]. On the symptomatic side, longitudinal [Figure 3a] and transverse [Figure 3b] scans revealed irregularity and focal discontinuity of the capitellar surface, along with a thin hypoechoic effusion in the radio-capitellar recess. No synovial hypertrophy, intra-articular loose body, or increased vascularity was detected on Doppler imaging.

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Figure 2:

Longitudinal ultrasound image of the contralateral (left) normal capitellum with smooth cortical outline.

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Figure 3:

(a) Longitudinal ultrasound of the affected right capitellum showing surface irregularity (yellow arrow) with hypoechoic effusion in the radio-capitellar recess. (b) Transverse ultrasound of the affected right capitellum showing cortical discontinuity and loss of smooth contour (yellow arrow) without intra-articular loose bodies.

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A diagnosis of Panner’s disease was made based on clinical and radiologic findings. The patient was treated conservatively with rest, non-steroidal anti-inflammatory drugs, and physiotherapy. At 6-week follow-up, he reported marked symptomatic improvement and complete restoration of motion. Follow-up imaging was not performed, which is acknowledged as a limitation.

DISCUSSION

Panner’s disease is a self-limited osteochondrosis confined to the capitellar ossification center. It is thought to result from repetitive valgus overload combined with transient ischemia. Although classically described in younger children, it can present in adolescents, creating overlap with OCD. Our case, in a 14-year-old cricketer, highlights this diagnostic challenge.

Radiographs typically show flattening, fragmentation, and subchondral sclerosis of the capitellum [Figure 1]. These features, correlated with the clinical setting, are often sufficient for diagnosis. Ultrasonography is a useful adjunct, offering radiation-free evaluation and contralateral comparison [Figures 2, 3a and b]. It confirms cortical irregularity, detects joint effusion, and excludes loose bodies.^[2]

MRI has an important problem-solving role. It can demonstrate marrow signal changes, cartilage involvement, and fragment stability. In Panner’s disease, MRI shows diffuse involvement of the entire ossification center, whereas OCD presents as a focal subchondral lesion with possible unstable fragments or intra-articular loose bodies. MRI is thus particularly useful when radiographs are equivocal or when symptoms persist.

Differentiation from OCD is crucial. OCD typically occurs in adolescents and young adults, involving the anterolateral capitellum. It is more focal, may cause fragment instability, and often requires surgical intervention if unstable. In contrast, Panner’s disease affects the entire ossification center, does not lead to loose fragments, and usually resolves with conservative treatment.^[3]

Expected follow-up imaging demonstrates progressive reossification, reconstitution of smooth cortical contour, and resolution of effusion on ultrasound. Although follow-up imaging was not available in this case, the clinical recovery supports the natural history of Panner’s disease.

Recent literature, including the review by Claessen et al., emphasizes that conservative management remains the mainstay, with excellent long-term outcomes in most cases.^[4]

CONCLUSION

Panner’s disease should be considered in active children and adolescents with lateral elbow pain. Radiography remains the cornerstone of diagnosis, while ultrasonography provides a valuable adjunct for assessing cortical integrity and excluding loose bodies. MRI is reserved for problem-solving and differentiation from OCD. Recognition of its self-limiting nature allows for effective conservative treatment and reassurance to young athletes and their families.