Osteochondrosis, Apophysitis, Other Bone-related pediatric injuries
February 9, 2024
Case 29 – Not Sural Be Climbing This Weekend
February 19, 2024

Case 28 – Child unable to kick injury

5-year-old malePresenting complaint unable to weight-bear on right footOngoing x 3 days.Mechanism injury no known mechanism injury but refusing to weight-bearWas in the emergency department day before had an x-ray that was reported as normal.  There was some soft tissue swelling noted at the time over the medial foot.
Mother was concerned and asked for second opinion.Past medical history noneMedications noneImmunizations up-to-dateAllergies no known drug allergiesExamination:
Well-appearing child, refusing to weight-bear on right side
Child hopping on left footThere is no warmth around the right ankle or foot however there is obvious soft tissue swelling over the medial midfoot dorsally
The navicular is point tenderNeurovascular otherwise normal
Xrays from initial visit:


Diagnosis: Kohler’s disease or avascular necrosis of the right navicular boneDiscussion: 
Kohler’s disease is an example of an osteochondrosis of the navicular bone.  It involves either atraumatic or traumatic avascular necrosis of the navicular bone in children, more often in boys, from 2  to 9 years of age (Alhamdani et al., 2017) (Gillespie, 2010).
There is no consensus on treating with immobilization or not (Houlden et al., 2021).  Immobilization may shorten pain period according to a retrospective chart review of 12 patients (Borges et al. 1995).
Given the condition, vitamin D 1000 units daily was recommended in this case, although there is no evidence for its use in this condition.   
They had follow up at 3 weeks:
By 6 week follow up, the child was weightbearing and returned to all activities.   The natural history of this condition is still under-studied.   Complications can include continued intermittent pain for 1 year to 18 months post initial injury.  It should also be noted that it may take up to this length of time to see normalization of radiographs (Borges et al., 1995).
Dr. Neil Dilworth, Dr. Chris Lu (2024/2/19 – PR MC )
Alhamdani M, Kelly C. Kohler’s disease presenting as acute foot injury. Am J Emerg Med. 2017 Nov;35(11):1787.e5-1787.e6. doi: 10.1016/j.ajem.2017.08.004. Epub 2017 Aug 2. PMID: 28801039.
Houlden R. Does immobilisation improve outcomes in children with Köhler’s disease? Arch Dis Child. 2021 Mar;106(3):303-305. doi: 10.1136/archdischild-2020-320548. Epub 2020 Oct 21. PMID: 33087388.
Borges, J. P. , Guille, J. T. & Bowen, J. (1995). Köhler’s Bone Disease of the Tarsal Navicular. Journal of Pediatric Orthopaedics, 15 (5), 596-598.
Gillespie, H. (2010). Osteochondroses and apophyseal injuries of the foot in the young athlete. Current Sports Medicine Reports9(5), 265–268. https://doi.org/10.1249/JSR.0b013e3181f19488