Ina Sorge (Kinderradiologie/Uni Leipzig)  

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13 Years  

Female  

Leg-Bones  

circulatory  

Pain initially in the left foot; a few months later also in the right foot, particularly on exertion. Slight swelling, pain on pressure.  

Aseptic bone necrosis are seen in children along with cartilage ossification defects throughout growth or throughout increased exertion. A cause may be passing intraossic vascularization disturbances through a mycotic-embolic vessel obstruction, bland infections, trauma, vessel spasms, vegetative dysregulations or vessel trauma. Constitutional and alimentary factors seem to play a role as well. The infestation can be unilateral or bilateral.  

<- view X-Ray 1

X-Ray 1: Left foot, October 2000: subchondral density and fragmentation of the 2nd metatarsal bone with undamaged joint.






<- view X-Ray 2

X-Ray 2: Left foot, November 2000: Flattening of the joint.






<- view X-Ray 3

X-Ray 3: Right foot, September 2001: Barely noticeable flattening and subchondral density of the head of the 2nd metatarsal.






<- view X-Ray 4

X-Ray 4: Right foot, December 2001: 3 Months after the first image shows an obvious flattening of the joints, beginning fragmentation.






<- view X-Ray 5

X-Ray 5: Right foot, October 2002: 1 year after disease began. Fragmentation, Break of the joint.






<- view X-Ray 6

X-Ray 6: January 2003: Late stage disease on both sides with deformation of the joint and beginning osteophytic structures as seen in a beginning secondary arthrosis.


 

Total constellation (Consens)  

none  

Freiberg-Kohler's disease is the only bone necrosis that is more often seen in girls than in boys.

II: partially detached osteochondral lesion

III: completely detached, non-displaced fragment

IV: detached and displaced fragment

There are 4 stages:
1. Initial stage with cartilaginous edema and joint effusion. The X-ray is still unnoticeable, in MRI bone marrow edema.

2. Condensation-density of bone structures in hypermineralization of necrotic bony trabecula. In the X-ray it is already seen, in MRI double-line sign.

3. Fragmentation with deformity of joint structures. Up until this stage, 2 or 3 years since begin of disease may have passed.

4. Repair with replacement of necrotic tissue with the new bone substance. Requirement: Revascularisation

An early diagnosis is possible , next to MRI, with the 3-phase skeletal szintigraphy. Avascular bone areas are known as so-called "cold-spots".

Treatment:
Conservative: decompression and increased circulation. bed rest, no sports, decompressing wraps, support insoles. Antiphlogistical, hyperemic and physical therapy. Prostaglandin analogs such as Ilomedin (Schering).

Surgical: Drilling to result in pressure decompression and increased revascularization. Nailing/Pinning, correction in Freiberg-Kohler as, for example, open-flap osteotomies in the later stages with pain and deformation.

The course of the disease is dependent on how fast vessels revascularize the area. An early diagnosis is therefore of great importance.  

The images show a phasic course of an osteonecrosis. On the right side Stage I (barely noticeable changes in X-Ray) up to a defect healing about 3 years later.  

N/A  

1. Medline:
G.Petje, C.Radler, N.Aigner, G.Kriegs-Au, R.Ganger, F.Grill
Aseptische Knochennekrosen im Kindesalter
Der Orthopäde 2002-31:1027-1038
 

aseptic bone necrosis, osteonecrosis, avascular necrosis, Kohler's Disease II, Freiberg-Kohler, avascular bone necrosis, child, childhood, pediatric radiology  

Ina Sorge. Kohler's Disease II, Bilateral Freiberg-Kohler Disease. PedRad [serial online] vol 4, no. 2.
URL: www.PedRad.info/?search=20040206232311