Köhler's Bone Disease

Osteochondroses are noninflammatory, noninfectious derangements of bony growth at various ossification centres occurring during times of great developmental activity. They affect the epiphyses.

Other osteochondroses include:

• Freiberg's disease - head of 2nd metatarsal
• Panner's disease - capitulum¹
• Blount disease - proximal tibia
• Sever's disease - calcaneus
• Sinding-Larsen-Johansson syndrome - patella

The aetiology of Köhler disease is unknown. Theories have included vascular trauma and retarded bone age, but none have been proven.²

Köhler's bone disease is rare.

• It commonly affects children aged 3 to 5 years old, but is seen any time between 2 and 10 years.³
• It is more common in boys, however girls with this condition are often younger than are boys with the disease. This is probably due to the onset of ossification in girls, which occurs at age 18-24 months, whereas in boys, ossification occurs at age 24-30 months.

Children present with:

• A unilateral antalgic limp
• Local tenderness of the medial aspect of the foot, over the navicular bone

The child is able to walk by taking the majority of their weight on the lateral aspect of the foot. Frequently, there is swelling and redness of the soft tissues.

Plain x-ray

X-rays comparing the affected with the unaffected side help assess progression.

• The navicular bone is initially flattened and sclerotic. Later, it becomes fragmented, and then re-ossifies.⁴
• The lateral view shows a flat tarsal scaphoid.
• The space between the talus and the cuneiforms is preserved.

MRI/CT

This is used if pain persists 6 months after casting. This is necessary to exclude a tarsal coalition. This is when the bones fuse and is a frequent cause of painful flatfoot in the older child or adolescent.

The mainstays of treatment are:

• Rest
• Avoiding excessive weight bearing
• Analgesia

Immobilisation, in a short leg cast moulded under the longitudinal arch, speeds up recovery.^5,6 Treating all patients for at least 6 weeks is recommended.

• If pain persists after a 6 week period of casting, a new cast must be applied for 6 supplementary weeks.
• Other causes of foot pain, (including talar coalition or an accessory navicular) should be excluded if the pain does not disappear after the cast has been in place.

The course is chronic, but rarely lasts longer than 2 years.⁷ Symptoms in treated patients can last for less than 3 months.