Panner disease is an

osteochondrosis Osteochondrosis is a family of orthopedic diseases of the joint that occur in children, adolescents and rapidly growing animals, particularly pigs, horses, dogs, and broiler chickens. They are characterized by interruption of the blood supply of a ...

of the

capitellum In human anatomy of the arm, the capitulum of the humerus is a smooth, rounded eminence on the lateral portion of the distal articular surface of the humerus. It articulates with the cupshaped depression on the head of the radius, and is limite ...

of the

elbow The elbow is the region between the arm and the forearm that surrounds the elbow joint. The elbow includes prominent landmarks such as the olecranon, the cubital fossa (also called the chelidon, or the elbow pit), and the lateral and the media ...

. Panner disease is primarily seen in boys between the ages of five and ten years old. Panner disease is often caused by excessive throwing due to

valgus stress The valgus stress test or medial stress test is a test for damage to the medial collateral ligament of the knee. It involves placing the leg into extension, with one hand placed as a pivot Pivot may refer to: *Pivot, the point of rotation in a ...

. The disease causes

pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...

and

stiffness Stiffness is the extent to which an object resists deformation in response to an applied force. The complementary concept is flexibility or pliability: the more flexible an object is, the less stiff it is. Calculations The stiffness, k, of a b ...

in the affected elbow and may limit extension; the affected elbow is usually on the dominant arm the child uses. The disease may be associated with pitching and athletic activity. On

radiograph Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...

s, the capitellum may appear irregular with areas of

radiolucency Radiodensity (or radiopacity) is opacity (optics), opacity to the radio wave and X-ray portion of the electromagnetic spectrum: that is, the relative inability of those kinds of electromagnetic radiation to pass through a particular material. Radi ...

. Treatment is

symptomatic Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showin ...

, with a good prognosis. Treatment is minimal and includes restricting athletic activity to allow for the elbow to heal and for pain to be relieved. The disease is named after the Danish radiologist Hans Jessen Panner (1871–1930).

Symptoms

An individual with Panner disease most commonly experiences elbow pain near the capitellum. Other symptoms include: *

Stiffness Stiffness is the extent to which an object resists deformation in response to an applied force. The complementary concept is flexibility or pliability: the more flexible an object is, the less stiff it is. Calculations The stiffness, k, of a b ...

in the elbow * Elbow swelling * Limited

range of motion Range of motion (or ROM), is the linear or angular distance that a moving object may normally travel while properly attached to another. It is also called range of travel (or ROT), particularly when talking about mechanical devices and in mechanic ...

* Elbow extension limitation * Tenderness These symptoms worsen with physical activity such a throwing a ball or

gymnastics Gymnastics is a type of sport that includes physical exercises requiring balance, strength, flexibility, agility, coordination, dedication and endurance. The movements involved in gymnastics contribute to the development of the arms, legs, shou ...

for example. The symptoms begin unexpectedly and are often present for several days or weeks, and the symptoms tend to last even longer.

Causes

Being an extremely

rare disease A rare disease is any disease that affects a small percentage of the population. In some parts of the world, an orphan disease is a rare disease whose rarity means there is a lack of a market large enough to gain support and resources for discove ...

, it is unknown as to what exactly causes Panner Disease. It is believed that the disease may be brought on by continuous overuse of the elbow and that puts pressure on the elbow and also strains the elbow in children during the period of rapid bone growth. The overuse of the elbow can be due to the involvement in sports such as

baseball Baseball is a bat-and-ball sport played between two teams of nine players each, taking turns batting and fielding. The game occurs over the course of several plays, with each play generally beginning when a player on the fielding tea ...

handball Handball (also known as team handball, European handball or Olympic handball) is a team sport in which two teams of seven players each (six outcourt players and a goalkeeper) pass a ball using their hands with the aim of throwing it into the g ...

, and

where these sports involve throwing or putting a lot of pressure on the

joint A joint or articulation (or articular surface) is the connection made between bones, ossicles, or other hard structures in the body which link an animal's skeletal system into a functional whole.Saladin, Ken. Anatomy & Physiology. 7th ed. McGraw ...

s. These repeated activities cause

microtrauma Microtrauma is any of many possible small injuries to the body. Microtrauma can include the microtearing of muscle fibres, the sheath around the muscle and the connective tissue. It can also include stress to the tendons, and to the bones (see ...

s and results in the affected elbow being

swollen Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels tight, the area ma ...

, irritated, and in

. Panner Disease results when the

blood supply The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...

to the

is disrupted and therefore the cells within the

growth plate The epiphyseal plate (or epiphysial plate, physis, or growth plate) is a hyaline cartilage plate in the metaphysis at each end of a long bone. It is the part of a long bone where new bone growth takes place; that is, the whole bone is alive, wi ...

of the capitellum die and it becomes flat due to the softening and collapsing of the surrounding bone.

Mechanism

Panner Disease affects the

of the arm. At the elbow, the

humerus The humerus (; ) is a long bone in the arm that runs from the shoulder to the elbow. It connects the scapula and the two bones of the lower arm, the radius and ulna, and consists of three sections. The humeral upper extremity consists of a roun ...

meets the

ulna The ulna (''pl''. ulnae or ulnas) is a long bone found in the forearm that stretches from the elbow to the smallest finger, and when in anatomical position, is found on the medial side of the forearm. That is, the ulna is on the same side of t ...

and the

radius In classical geometry, a radius ( : radii) of a circle or sphere is any of the line segments from its center to its perimeter, and in more modern usage, it is also their length. The name comes from the latin ''radius'', meaning ray but also the ...

. The humerus is the long bone that runs from the shoulder to the elbow, and the ulna and radius are the two bones that make up the forearm. The

is the rounded knob on the end of the humerus and it is held by the radius due to the radius's cup-like shape. Panner Disease is part of a family of bone development diseases known as

. In osteochondrosis, the blood supply to an area of developing bone in the dominant elbow is temporarily disrupted by something that is not yet well understood. Therefore, the tissues in the bone are not getting enough blood and they begin to go through

necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...

, and they begin to die. Normally, bones grow by the expansion and uniting of the

growth plates The epiphyseal plate (or epiphysial plate, physis, or growth plate) is a hyaline cartilage plate in the metaphysis at each end of a long bone. It is the part of a long bone where new bone growth takes place; that is, the whole bone is alive, with ...

, but osteochondrosis disrupts this process and the result is cell death and the loss of newly formed tissue. The death of the tissues eventually leads to deterioration of the bone's

. The bone's growth plate is defined as the area at the end of a developing bone where cartilage cells change into bone cells. The bone tissue does regrow, but the necrosis can cause temporary problems in the affected area until the strenuous arm and elbow activity is significantly decreased or stopped for a period of time. It is believed that Panner Disease is a precursor to a similar condition called osteochondritis dissecans of the capitellum ( OCD). OCD is different from Panner disease because OCD occurs in older children and it does not involve the growth plate because by the time that OCD occurs the growth plates have already fused and the skeleton has finished growing.

Diagnosis

As the symptoms become prominent, the child will visit their

pediatrician Pediatrics ( also spelled ''paediatrics'' or ''pædiatrics'') is the branch of medicine that involves the medical care of infants, children, adolescents, and young adults. In the United Kingdom, paediatrics covers many of their youth until the ...

family doctor Family medicine is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body. The specialist, who is usually a primary ...

to confirm whether or not the child has Panner Disease. When the child visits the doctor, the doctor will seek information about the child's age, sports participation, activity level, and what the child's dominant arm is. The affected elbow will be compared to the healthy elbow and any differences between the two will be noted. The location of where the pain is in the elbow, and the child's

and extension will also be determined to make an accurate

diagnosis Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...

. To check the child's range of motion and extension limitation the child will be asked to move the arm of the affected elbow in various directions. The movement of the arm in various directions will allow the doctor to conclude how good the child is able to move the arm and the doctor will be able to determine if there is pain caused by the various directions of movement. To confirm the diagnosis, an

x-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...

scan will be done. The

will enable the doctor to visualize irregularities and see the shape of the

and also visualize the

. In Panner Disease, the

may appear flat and the bone growth plate will look irregular and fragmented. The areas where bone breakdown has occurred can also be visualized on the radiograph. When the patient undergoes an MRI scan any irregularities of the capitellum will be able to be visualized, and the bone will be able to be visualized in more detail to determine the extent of swelling, if any. In the MRI results for Panner disease, there will be a decreased signal intensity of the capitellum on a T1 series and increased signal intensity on a T2 series.

Prevention

To prevent future instances of Panner Disease the child is instructed to cease all physical and sports activities that involve the use of the affected elbow until the symptoms are relieved

Treatment

The goal of treatment in Panner disease is to relieve

. Treatment for Panner Disease is very minimal because in most children the bones repair their blood supply and rebuild themselves and this leads to the rebuilding of the

and the

returns to its normal shape. The period of rebuilding and regrowth varies from child to child and can last anywhere between weeks to several months. To relieve the pain, the child is restricted from participating in sports and activities until the elbow is healed and to also rest the affected elbow. Rest will allow for the pain to be relieved and return of full elbow movement. It may also be recommended for children to apply an icepack or heat to the elbow to alleviate pain and swelling. If the child has great difficulty bending and straightening the arm then physical therapy may also be recommended. Occasionally, it is recommended for children to use nonsteroidal anti-inflammatory drugs (NSAIDs) or

acetaminophen Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. Common brand names include Tylenol and Panadol. At a standard dose, paracetamol only slightly decreases body temperature; it is inferior ...

to also reduce pain and swelling.

Prognosis

For treatment, Panner Disease heals well in children with rest and restriction of

physical activity Physical activity is defined as any voluntary bodily movement produced by skeletal muscles that requires energy expenditure.Global Recommendations on Physical Activity for Health, 2009. World Health Organization. Geneva, Switzerland. Accessed 13/ ...

and sports using the affected arm. The prognosis is also good with treatment and the affected

is remodeled. Irregularities of the capitellum and surrounding elbow area can both be seen by

and

. When treatment is effective the flattened and fragmented capitellum is completely remodeled and returns to its normal circular shape, and also the high intensity signal on an MRI T2 series disappears. These results indicate that the capitellum is completely remodeled and the child is able to return to normal physical and sports activities.

Research

Although the exact cause of Panner Disease is unknown, in recent research, it has been concluded that it may be associated with frequent throwing or other athletic activity. In the same article that talks about varying

diseases, it is pointed out that Panner Disease always involves alteration of the

, which can be visualized by

radiography Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...

. In another research article, the research team aimed to summarize the best available evidence for diagnosis and treatment for Panner Disease. In the article it was found that the most common symptoms that patients with Panner Disease present with are elbow

and swelling, limited

, and limited elbow extension. In alignment with the previously mentioned article, the team of researchers also concluded that Panner Disease involves irregularity of the capitellum, specifically that it appears flattened. Panner Disease often gets misdiagnosed as osteochondritis dissecans (OCD), and in this article they distinguish the difference between the two diseases are age difference and radiographic findings. In alignment with the two previously discussed articles, another article that reports on three case studies of Panner Disease, states that the primary treatment that is used for Panner Disease is rest and restriction from all physical and athletic activity that involves the use of the upper extremities; the activity is suggested to be ceased until the symptoms are relieved.

References

External links

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