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Year : 1999  |  Volume : 9  |  Issue : 3  |  Page : 153-154
Osteochondritis of the tarsal navicular bone (kohler's disease) occurring in a child with acute lymphoblastic leukemia

Regional Cancer Centre, Trivandrum, India

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How to cite this article:
Ramachandran K R, Sasidharan K, Kusumakumary P, Ittiyavirah A K, Krishnakumar A S. Osteochondritis of the tarsal navicular bone (kohler's disease) occurring in a child with acute lymphoblastic leukemia. Indian J Radiol Imaging 1999;9:153-4

How to cite this URL:
Ramachandran K R, Sasidharan K, Kusumakumary P, Ittiyavirah A K, Krishnakumar A S. Osteochondritis of the tarsal navicular bone (kohler's disease) occurring in a child with acute lymphoblastic leukemia. Indian J Radiol Imaging [serial online] 1999 [cited 2020 Aug 15];9:153-4. Available from:

Osteochondritis is a disease of one or more epiphyses beginning as a necrosis followed by healing. Osteonecrosis is commonly encountered in children treated for hematological malignancies, especially with a steroid-containing regime. However the incidence is much less as compared to avascular necrosis. We report a case of osteochondritis of the tarsal navicular bone in a seven-year old child undergoing treatment for acute lymphoblastic leukemia (ALL) in our institution, with a steroid-containing regime.

A four-years old child was brought to our outpatient department in September 1995, with complaints of irregular fever and pain in both lower limbs of three months duration. Clinical and laboratory examination revealed evidence of acute lymphoblastic leukemia

He was treated with a chemotherapeutic regime which included steroids and he went into remission. He had a bone marrow relapse in February 1998. He was started on re-induction chemotherapy which included prednisolone. While on chemotherapy he complained of severe pain in the left ankle region. Radiographs of the left foot [Figure - 1],[Figure - 2] revealed irregular sclerosis, condensation and fragmentation of the navicular. The findings were diagnostic of osteochondritis of the navicular bone (Kohler's disease).

The pathological changes of osteochondritis are usually explained on the basis of aseptic necrosis, due to vascular occlusion. The areas of necrosis eventually undergo repair and are subsequently converted into normal bone[1]. Necrosis of bone may occur as a complication of several disorders. It has been associated with corticosteroid administration either of long or short duration [2]. Its occurrence in malignant diseases such as lymphomas, leukemias, etc. has been described [2],[3]. Children with ALL treated with combination chemotherapy sometimes complain of bone or joint pain. This may be due to osteonecrosis or osteochondritis. Osteonecrosis has been reported to occur in symptomatic patients, anywhere from two months to eleven years after the beginning of therapy with a frequency of 3-85 % [4]. MR imaging is the investigation of choice for the diagnosis of early cases.

There are not many reports of osteochondritis especially of the tarsal navicular bone, occurring during the treatment of ALL. Kohler's disease is seen between three to ten years of age and is more common in boys. The child presents with a limp, pain, tenderness and swelling in the region of the navicular bone [5]. In the early phase, the disease is characterized by irregularity of the navicular bone with fissuring. Later, fragmentation, condensation and increased density of bone are noted. Gradually, repair occurs and the bone regains its shape and texture. The whole process may take upto two years.

The main differential diagnosis is delayed ossification, wherein the bone appears fragmented [5]. Bone marrow infarctions commonly occur in patients with hematological malignancies. Kohler's disease may occur as a co-existent phenomenon in this kind of a setting or may be a result of high-dose steroid intake.

   References Top

1.Jacobs P, Murray RO, Stoker DJ. Avascular necrosis of bone: osteochondritis, miscellaneous bone lesions. In: David Sutton, ed. Textbook of Radiology and Imaging. 3rd. ed. Edinburgh: Churchill Livingstone 1980: 54-66.   Back to cited text no. 1    
2.Murphy RG Greenberg ML. Osteonecrosis in paediatric patients with acute Lymphoblastic leukaemia. Cancer 1990; 65: 1717-1721.   Back to cited text no. 2    
3.Engel IA, Straus DJ, Lacher M, Lane J, Smith J. Osteonecrosis in patients with malignant Lymphoma: a review of twenty five cases. Cancer 1981; 48:1245-1250.   Back to cited text no. 3  [PUBMED]  
4.Pieters R, Van Brenk I, Veerman AJP, Van Amerongen AHMT, Van Zanten TEG, Golding RP. Bone marrow Magnetic Resonance studies in childhood leukaemia: evaluation of osteonecrosis. Cancer 1987; 602994-3000.   Back to cited text no. 4    
5.Thomas PS, Renton P, Hall C, Kalifa G, Dibousset J, Lalande G. The musculoskeletal system. In: Carty H, Shaw D, Brunelle F, Kendall B eds. Imaging children. Edinburgh: Churchill Livingstone, 1994: 1054.   Back to cited text no. 5    

Correspondence Address:
K R Ramachandran
Regional Cancer Centre, Trivandrum
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Source of Support: None, Conflict of Interest: None

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[Figure - 1], [Figure - 2]


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