Author: BuMin Kong, MD; Susie Lee, BA
Peer-Reviewer and Final Editor: Mark Hopkins, MD
5 year-old previously healthy male presents to the ED for one week of atraumatic right foot pain and limp. Physical exam shows tenderness over the proximal dorsal aspect but no swelling or erythema.
Image 1. Courtesy of BuMin Kong
What is your diagnosis?
What is the cause?
What is your treatment in the ED?
What is your disposition?
-- See below for answers --
What is your diagnosis?
Kohler's disease is an avascular necrosis of the navicular bone. The navicular bone on Image 1 appears sclerotic, wafer-like, and thin on X-ray. Image 2 is a normal 7 year-old foot for comparison.
Image 2. Case courtesy of Dr Aneta Kecler-Pietrzyk, Radiopaedia.org, rID: 53079. Annotation by Authors
Pearl: Kohler's disease occurs mainly in males around 4-7 years of age. The adult counterpart to this disease is called Mueller-Weiss syndrome
What is the cause?
The exact pathophysiology is unknown but is believed to be a compression of the navicular bone prior to ossification which compromises blood flow and results in avascular necrosis. [1]
Pearl: The navicular blood supply is a watershed zone which makes it susceptible to avascular necrosis
What is your treatment in the ED?
Treat initially with a short-term course of NSAIDS for symptom relief. If there is significant pain with activity, a short leg cast can be used for 6-8 weeks. [2]
Pearl: Kohler's disease is generally self-limiting but may take up to 3 years for symptom resolution. There is no long-term disability associated with this diagnosis. [1]
What is your disposition?
The patient can be discharged and follow up with an orthopedic or sports medicine physician in 2-4 weeks.
Reference
1. Trammell AP, Davis DD, Scott AT. Kohler Disease. 2020 Dec 2. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29939608.
2. Williams GA, Cowell HR. Köhler's disease of the tarsal navicular. Clin Orthop Relat Res. 1981 Jul-Aug;(158):53-8. PMID: 7273526.
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