Making the diagnosis – that’s what it’s all about.
Even after 25 years in practice, there’s still one thing that gets me excited,
and that’s making a really good diagnosis. In a way it’s a bit like being Sherlock Holmes who famously said in 1892 in, A Scandal in Bohemia, “You see but you do not observe. The distinction is clear.” You don’t have to be a rocket scientist to make a good diagnosis. You just need to observe. And observe  carefully.
This week I saw a 6 y/o who had fallen off of his coffee table at home. He presented to a rural hospital ER for x-rays that were read, “ankle free of injury, no fracture.” He and his mom presented to my Chillicothe office with the plain films and the report. But something wasn’t right. On the ER films the left navicular seemed irregular. The boy was active with no limp in his gait. But with palpation of the midfoot and range of motion with the heel locked, there was some mid-foot pain. On a hunch, I got x-rays of the asymptomatic foot. And what I observed was two strikingly different navicular(s). The right was well formed and the left was sclerotic (bright white) and thin.
The diagnosis was Kohler’s Disease. Kohler’s Disease, also known as aseptic necrosis of the navicular, is a relatively rare finding in children. In fact I can’t remember the last case that I have seen. Aseptic means free of infection. Necrosis means that the blood flow to the navicular had been cut off and the bone had died.Â
So what to do? Some advocate a non-weight bearing cast. If this particular child had been more symptomatic, I think I would have seriously considered that as an option. Mom suggested a rigid arch support and that was a good call. But until we see an increase in symptoms, I think we’re best to simply decrease activities; no basketball leagues, no traveling soccer.
Aseptic necrosis follows a fairly unpredictable path of 4 stages. First is early recognition usually due to pain. Second is decrease mineral content of the bone (that’s the avascular aspect). Third is collapse and fourth is a remodelling phase. Although these stages overlap, we could say that this child was in stage 3 and entering stage 4.Â
I don’t believe that it was Kohler’s Disease that caused the pain following the fall. It was the fall that seem to stir up the coals. The radiographic changes were not just a week old. So this stoic little kid had been putting up with this for months.
Observe what you see. How cool is that?
Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.
Tags: aseptic necrosis, kohlers disease, navicular
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