Patient Presentation
An 11-year-old male came to orthopaedic clinic with a history of injuring his right ankle 2 years ago in a soccer game.
He thinks he may have twisted it but is unsure. The injury didn’t appear significant and he was not evaluated.
Since then he has had intermittent right ankle pain after mild trauma (i.e. sliding into a base during baseball) or high activity levels.
The pain is always in the same location and sometimes there is mild swelling.
It has not stopped him from playing sports, he has not taken any medication and is able to walk without problems during the pain.
The family history, past medical history and review of systems was negative.
The social history reveals a boy who is doing well in school and participates on many athletic teams.
The pertinent physical exam showed a male with 75-90% growth parameters and who was well appearing.
His musculoskeletal examination revealed mild pain with dorsiflexion and inversion of the right ankle. There was pain over the navicular bone medially. The rest of his examination was normal.
Review of his locally obtained radiographs revealed an irregular ossification of the navicular bone consistent with the diagnosis of Köhler’s disease or osteochondrosis of the tarsal navicular bone.
The patient was allowded to continue his activities and a shoe insert was prescribed to provide more cushioning and distribution of the forces on the foot.
He was to return in 6 months for re-evaluation. If there was worsening symptoms or signs of disease, a computed tomograph examination would be ordered to evaluate for possible bone fragments or other problems that would need surgical correction.
Discussion
Osteochondroses are pathological changes in a bone growth center that are caused by ischemic necrosis or traction.
The causes are not well known but vascular accidents, coagulation and genetics are implicated.
Two common osteochondroses are Osgood-Schlatter disease or apophysitis of the tibial tubercle, and Legg-Calvé-Perthes caused by ischemic necrosis of the capital femoral epiphysis and others.
About 40 osteochondroses are eponymously named: Osgood (American) and Schlatter (Swiss) who described this disease almost simultaneously in 1903.
Similarly, Legg (American), Calvé (French) and Perthes (Germany) described their osteochondrosis separately but almost simultaneously in 1908.
Interestingly Waldenström (Swedish) also described the disease during the same time period but his name is not as consistently associated with the disease.
Alban Köhler was a German radiologist. His name is also associated with Freiberg (American) to describe osteochondrosis of other foot bones.
Learning Point
Köhler’s disease is more common in boys than girls, and occurs most often in 5-10 year olds. Exact cause is unknown but there is disruption of vascular supply to the bone which then causes necrosis; later revascularization causes reformation of the bone.
Patients can present with an antalgic limp and point tenderness of the navicular medially. Generally, children can walk and there may be soft tissue swelling or redness.
Radiographs show irregular ossification of the navicular bone.
Treatment is usually just monitoring. Patients generally may ambulate but sometimes casting for 6-8 weeks is recommended. Usually patients are better in 3-6 months but some may have a delay in healing. Most patients do not have any complications.
Questions for Further Discussion
1. What should be considered in the differential diagnosis of chronic foot pain?
2. When should a patient be referred to an orthopaedist?
3. When should a patient be referred to a podiatrist?
Related Cases
- Disease
- Köhler’s Disease
Osteonecrosis
Foot Injuries and Disorders
- Symptom/Presentation
- Specialty
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for these topics: Osteonecrosis and Foot Injuries and Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Mier, RJ, Brower TD. Pedatric Orthopedics. A Guide for Primary Care Physicians. Plenum Medical Book Company, New York. 1994;39-47.
Vargas-Barreto B, Clayer M. Köhler’s Disease. eMedicine. Available from the Internet at http://www.emedicine.com/orthoped/TOPIC410.HTM (rev. 9/18/2007, cited 4/7/2008).
Alban Köhler. Who Named It.
Available from the Internet at http://www.whonamedit.com/doctor.cfm/2302.html (rev. 2008, cited 4/7/08).
Calvé-Legg-Perthes disease. Who Named It.
Available from the Internet at
http://www.whonamedit.com/synd.cfm/908.html (rev. 2008, cited 4/7/08).
Köhler Disease I. Who Named It.
Available from the Internet at http://www.whonamedit.com/synd.cfm/2676.html (rev. 2008, cited 4/7/08).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Date
May 19, 2008
Pediatric Education 