Updated: 12/7/2016

Kohler's Disease

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Questions
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Introduction
  • Avascular necrosis of the navicular bone of unclear etiology
  • Epidemiology
    • demographics
      • occurs in young children (usually age 4-7 yrs)
      • four times more common in boys than girls
        • 80% of cases in boys
    • locations
      • can be bilateral in up to 25% of cases
  • Pathophysiology
    • the blood supply of the central one third of the navicular is a watershed zone
      • accounts for the susceptibility to avascular necrosis and stress fractures
    • the navicular is the last bone to ossify
      • increases its vulnerability to mechanical compression and injury
  • Associated conditions
    • infection
      • Kohler's disease is often misdiagnosed as infection
  • Prognosis
    • typically a self-limiting condition
    • intermittent symptoms for 1-3 years after diagnosis
      • typically associated with activity
Classification
  • There is no widely used classification system for this condition
Presentation
  • History
    • patient may not have complaints as disease can be asymptomatic
    • characteristically described as midfoot pain with an associated limp
  • Symptoms
    • pain in dorsomedial midfoot
    • may have swelling, warmth, and redness
    • point tenderness over the navicular
  • Physical exam
    • antalgic limp (may place weight on lateral side of foot)
Imaging
  • Radiographs
    • characteristic sclerosis, fragmentation, and flattening of tarsal navicular
    • most tarsal navicular bones reorganize after disease has run its course
      • some continue to be deformed but almost all of those remain asymptomatic
Treatment
  • Nonoperative
    • NSAIDs
      • short course can be used to decrease symptoms
    • immobilization with short leg walking cast q q   
      • indications
        • pain with activities
      • outcomes
        • studies have shown treatment in a short leg walking cast will decrease the duration of symptoms
        • radiographs improve at around 6-48 months from onset of symptoms
        • no reports of long-term disability
  • Operative
    • surgery
      • indications
        • not indicated for this disease
 

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Questions (5)
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(OBQ08.109) A 6-year-old boy presents to your office with foot pain that is increasing in severity. His parents state he has recently been limping. There is no history of trauma and he is otherwise healthy. Radiographs are shown in Figures A and B. Which of the following is the most appropriate treatment for this child?
Review Topic

QID: 495
FIGURES:
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1

Observation

16%

(559/3406)

2

Open biopsy and curettage

3%

(104/3406)

3

Long leg non-walking cast

9%

(302/3406)

4

Chopart amputation

0%

(2/3406)

5

Short leg walking cast

71%

(2425/3406)

L 2

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(SAE07PE.70) A 5-year-old boy has had pain in the right foot for the past month. Examination reveals tenderness and mild swelling in the region of the tarsal navicular. Radiographs are shown in Figure 30. Management should consist of Review Topic

QID: 6130
FIGURES:
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1

biopsy of the tarsal navicular.

4%

(7/171)

2

curettage and bone grafting of the tarsal navicular.

3%

(5/171)

3

CBC count, C-reactive protein level, erythrocyte sedimentation rate, blood cultures, and IV antibiotics.

6%

(10/171)

4

symptomatic treatment with restriction of weight bearing or application of short leg cast.

82%

(140/171)

5

medial column lengthening of the foot through the tarsal navicular.

5%

(8/171)

L 2

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(OBQ04.17) A 5-year-old boy presents with a limp and pain over the medial aspect of the foot. Radiographs are shown in figures A and B. Orthotics have failed to improve his symptoms. What is the next appropriate management of this condition? Review Topic

QID: 128
FIGURES:
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1

core decompression

13%

(148/1098)

2

triple arthrodesis

2%

(22/1098)

3

subtalar fusion

2%

(17/1098)

4

IV antibiotics with irrigation and debridement

3%

(32/1098)

5

short-leg walking cast

79%

(871/1098)

L 1

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SUBMIT RESPONSE 5
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