What is the assessment and management plan for a 4-year-old diagnosed with Kohler disease?

Assessment and Management of Köhler Disease in a 4-Year-Old Child

Köhler disease in a 4-year-old child should be managed conservatively with short-term immobilization using a walking cast to reduce symptom duration, followed by supportive care until spontaneous resolution occurs. 1

Clinical Presentation and Diagnosis

• Köhler disease is an osteochondrosis (avascular necrosis) of the tarsal navicular bone that typically affects children between 2-10 years of age, with boys more commonly affected than girls 1

• The child may present with:

  • Pain in the medial region of the foot with mechanical characteristics 2
  • Limping (intermittent or continuous) which may be the only clinical manifestation 2
  • Inability to bear weight after activity or minor injury 3
  • Swelling of the medial midfoot 1

• Radiographic findings typically show:

  • Increased sclerosis of the navicular bone 1
  • Flattening of the navicular bone 2
  • Irregular rarefaction or fragmentation of the navicular bone 2, 1
  • Bilateral involvement is possible, though symptoms may present unilaterally 2, 4

Management Plan

Immediate Management

• Short-leg walking cast immobilization for 4-8 weeks is recommended for symptomatic relief 1, 4
  • This approach reduces the duration of symptoms compared to no immobilization
  • Cast should be well-molded to provide adequate support to the medial arch

Alternative Management Options

• For milder cases, shoe supports or orthotic devices may be sufficient 4
• Non-steroidal anti-inflammatory medications can be used for pain management as needed
• Activity modification with reduced weight-bearing activities until symptoms improve

Follow-up Care

• Clinical reassessment after 4 weeks of immobilization 2
• If symptoms persist, continue immobilization for additional 2-4 weeks 4
• Once symptoms resolve, gradual return to normal activities
• Follow-up radiographs may show persistent abnormalities despite clinical improvement, which is expected and does not require additional treatment

Prognosis and Parent Education

• Köhler disease is self-limited with favorable long-term outcomes regardless of treatment approach 2, 1
• Parents should be informed that:
  • Complete resolution of symptoms typically occurs within 4-8 weeks of appropriate management 2
  • The navicular bone will eventually reossify and return to normal shape over time
  • No long-term functional limitations are expected 1
  • Recurrence is rare after complete resolution

Common Pitfalls to Avoid

• Misdiagnosis as infection or trauma, leading to unnecessary tests and treatments 2, 3
• Failure to consider bilateral involvement even when symptoms are unilateral 2, 4
• Overtreatment with prolonged immobilization beyond what is necessary for symptom relief
• Unnecessary concern about persistent radiographic abnormalities after clinical improvement
• In cases where diagnosis is uncertain, additional imaging with Tc-99m hydroxydiphosphonate SPECT/CT can help localize the pathology to the navicular bone 5