Review of Keller's disease (types 1 and 2): causes, stages, signs and treatment

Author of the article: Victoria Stoyanova, category 2 doctor, head of the laboratory at the diagnostic and treatment center (2015–2016).

Article publication date: 07/25/2016

Article updated date: 01/28/2020

Keller's disease is the death of individual bones in the feet. This pathology refers to osteochondropathy – diseases accompanied by the destruction of spongy bone tissue due to a lack or complete cessation of its blood supply.

There are 2 types of this disease:

1. with pathological changes in the scaphoid bone
2. with damage to the heads of the II and III metatarsal bones of the feet.

The structure of the ankle joint

Both species have the same development mechanism. Destructions in spongy bone tissue occur due to a disorder in its blood supply - this is a chronic process that lasts a long time. Lack of oxygen and nutrients leads to the destruction of bone tissue, then aseptic necrosis develops (necrosis - necrosis, aseptic - that is, without the participation of microbes).

Subsequently, the bone tissue slowly recovers on its own, but in the absence of quality treatment, there is a high probability of complications in the form of irreversible deformities of the foot. If treatment was started on time and the patient completed the entire course, then the duration of the disease is significantly reduced, and the functions of the feet are fully restored without any irreversible consequences.

A characteristic feature of this pathology is the gradual destruction of bone in the absence of inflammation, followed by its restoration.

This pathology is diagnosed mainly in young children and adolescents. Keller's disease 1 is more often detected in 3-7 year old boys, the second type - in 10-15 year old girls. The development of pathology is also possible in young people 20–25 years old.

Symptoms of the disease negatively affect the child’s motor activity: pain when walking and swelling of the foot lead to changes in gait, lameness, and inability to run. The situation is complicated by microfractures in the area of ​​bone damage.

The treatment is carried out by an orthopedist; it is to him that the child should be taken if pain occurs in the area of ​​the feet. Coping with the disease is not so difficult - you just need patience and attentive attitude towards your child. And the doctor will monitor the entire process of treatment and rehabilitation and give recommendations in order to further minimize the load on the affected bones.

Further from the article you will learn about the causes, stages of the course, signs, diagnostic methods and stages of treatment of this disease.

General information

Keller's disease is a disease that affects the bones of the foot. As a rule, it is diagnosed in adolescence and childhood. The development of this disease is expressed by osteochondropathy - a gradual process of destruction of bone tissue and its subsequent restoration.
This disease was first described by radiologist Keller from Germany; this happened at the beginning of the last century. When a person develops Keller's disease, the body experiences disruption of blood flow to the bones of the foot. As a result, the feet do not receive the required amount of oxygen and a number of nutrients necessary for the normal functioning of tissues. The process of bone tissue dying begins, which in medicine is commonly called aseptic necrosis . Death of foot tissue in Keller's disease occurs without the participation of infectious processes. Among the variety of ailments of the human skeletal system, osteochondropathy accounts for approximately 3%.

Treatment methods

Treatment of both types of Keller disease follows the same type of treatment.

(if the table is not completely visible, scroll to the right)

The recovery period after removing a cast or undergoing surgery should be taken with particular seriousness. It is important to limit the child’s motor activity: avoid jumping, running and any active games. Choose orthopedic shoes for him, when worn, the feet will retain their anatomically correct shape (special insoles will reduce pressure on the bones affected by necrosis).

As a result, nutrition and regeneration of damaged tissues will occur faster.

Causes

The disease manifests itself as a consequence of a number of reasons that lead to deterioration of blood circulation in the foot area. First of all, these are various foot injuries, constant wearing of tight and uncomfortable shoes of the wrong size. Keller's disease can develop in people suffering from arthritis , arthrosis , as well as some diseases associated with endocrine and hormonal disorders. Another important factor in this case is the hereditary predisposition to the development of this disease. Acquired or congenital foot defects (most often flat feet ) can also lead to the manifestation of this disease. An important factor is also the disruption of metabolic processes in the human body. However, experts note that the exact causes of osteochondropathy are still not completely known.

Medical Scientific and Practical Center for Vertebrology and Neuroorthopedics, Professor M.L. Kurganov

Osteochondropathies are a group of diseases that occur in childhood and adolescence due to malnutrition of bone tissue . In the area of ​​the bone, the blood supply is disrupted and areas of necrosis appear. The disease most often occurs in the epiphyses and apophyses of the tubular bones of the arms, legs and vertebrae. The epiphysis is the site of bone tissue growth. Apophysis is a protrusion of bones near the growth plate to which muscles and ligaments are attached. Usually this is the terminal part of a long tubular bone. The disease is chronic and often develops in the lower extremities , which are under greater load. Most osteochondropathy has a hereditary basis.

Legg-Calvé-Perthes disease.

Legg-Calvé-Perthes disease or chondropathy of the femoral head is also called juvenile osteochondrosis of the femoral head. Boys aged 4 to 12 years are more likely to get sick. Usually, injury to the hip joint area occurs first, then the blood supply to the femoral head is disrupted.

First, necrosis of areas of the bone tissue of the femoral head occurs. This can be seen on an x-ray. In the second stage of the disease, the head of the femur is flattened under the influence of heavy load. The next stage is called the fragmentation stage. In this case, resorption of areas of necrotic bone tissue occurs. In the absence of treatment, the fourth stage occurs - osteosclerosis. The femoral head is restored, but its normal shape is changed. The final stage, with insufficient treatment, is deforming arthrosis of the hip joint with disruption of its function.

At the beginning of the disease, there are practically no complaints. Then pain appears in the hip joint, which radiates to the knee. Pain often occurs after exercise and disappears after rest and at night. The child may not pay attention to the pain and not complain. Gradually, restriction of movements in the hip joint occurs. During this period, you may notice weight loss in the thigh on the affected side, caused by muscle atrophy. X-rays are taken to make a diagnosis. Radiologically, five stages of the disease are distinguished, corresponding to changes in the femoral head.

Treatment can be surgical or conservative. Conservative treatment includes mandatory bed rest. The patient is forbidden to even sit in order to eliminate the load on the head of the femur. Skeletal traction is applied to both hips. Daily massage of the lower extremities and physiotherapeutic treatment are prescribed. Surgical treatment consists of performing various osteoplastic operations. The types of surgical interventions depend on the stage of the disease.

Keller's disease. This is chondropathy of the bones of the foot. There are Keller disease I and Keller disease II.

Keller disease I is a chondropathy of the navicular bone of the foot. The disease develops in childhood from 4 to 12 years. The patient experiences pain and swelling of the upper (dorsal) surface of the foot above the navicular bone. The pain intensifies while walking. The child is limping. To clarify the diagnosis, x-rays of the foot bones are taken. A change in the shape of the scaphoid bone and its fragmentation are detected.

Treatment consists of unloading the foot. A plaster cast is applied for 4-6 weeks. After the cast is removed, physical therapy and physiotherapeutic procedures are prescribed, which are combined with reducing the load on the foot. For 1-2 years, the child must wear orthopedic shoes.

Keller disease II is a chondropathy of the metatarsal heads. The second metatarsal bone is most often affected by the disease. The patient experiences pain in the affected area. The pain increases sharply when walking, especially barefoot on uneven surfaces and wearing shoes with soft soles. Shortening of the fingers may occur. When palpated, a sharp pain in the bases of the fingers is detected. The heads of the metatarsal bones increase in size. The diagnosis and stage of the disease are clarified using x-rays.

Treatment of Keller II disease is conservative. The foot is unloaded. To do this, a plaster boot is applied for one month. Then the child must wear orthopedic shoes, since there is a high risk of developing flat feet. Massage, physiotherapeutic procedures, and therapeutic exercises are used. The disease lasts 2-3 years. In the absence of a good effect from conservative therapy and the development of severe deforming arthrosis of the joint, surgical treatment is prescribed.

Kienbeck's disease.

This is chondropathy of the lunate bone of the hand. It manifests itself by the development of aseptic necrosis in this bone. The disease develops in men 25-40 years old after major injuries or prolonged microtraumatization of the hand, when working with heavy physical load on the hands. The patient experiences discomfort in the hand and constant pain, which intensifies with exercise and movement. Swelling occurs at the base of the hand. Limitation of mobility in the wrist joint gradually develops. Limitation of joint mobility in turn causes a decrease in the work of the forearm muscles and their atrophy. The diagnosis is confirmed using x-ray examination.

Treatment of Kienböck's disease. The load on the bone is limited. To do this, a plaster cast is applied for 2-3 months. After removing the cast, massage, physiotherapeutic procedures, and physical therapy are prescribed. When severe deforming arthrosis develops, surgical treatment is used.

Schlatter's disease or Ostgood-Schlatter disease.

Schlatter's disease occurs in boys from 12 to 16 years old, especially in those who play sports, dance sports, and ballet. Under increased load, chondropathy of the tibial tuberosity develops. The tibial tuberosity is located on its anterior surface, below the patella. The quadriceps femoris muscle is attached to the tibial tuberosity.

In young men, the process of ossification of the tibial tuberosity is not yet completed, and it is separated from the tibia proper by a cartilaginous zone. With constant load on the tuberosity, the blood supply is disrupted, and areas of the tuberosity undergo necrosis and then restoration. By the age of 18, the tuberosity fuses with the tibia and recovery begins. The patient complains of pain below the patella and swelling. The pain intensifies when the quadriceps muscle is tense, when climbing stairs, or squatting.

The diagnosis is confirmed by x-ray. Treatment consists of eliminating the load on the quadriceps femoris muscle. Warmth and physiotherapeutic procedures are prescribed. If the pain is severe, a plaster cast is applied. Occasionally, it is necessary to use surgical methods, which involve surgical removal of a fragment of the tibial tuberosity.

Osteochondropathies of the vertebral bodies

Calvet's disease.

Calvet disease is chondropathy of the vertebral body. Most often, the disease affects the lower thoracic or upper lumbar vertebrae. Boys from 7 to 14 years old are affected. The patient experiences pain in the area of ​​the affected vertebra or in the thoracic and lumbar spine. Upon examination, you can detect a protruding spinous process of the diseased vertebra. When palpating the spinous process, the pain intensifies. An x-ray reveals a sharp decrease in the height of this vertebra and its expansion.

Treatment of Calve's disease is conservative. Bed rest is prescribed in a special position on the bed to reduce the load on the vertebra. Physical therapy is used, which consists of a set of exercises to strengthen the back muscles to create a muscle corset. After this, the patient must wear a special corset for several years. Surgical treatment is prescribed in the absence of effect from conservative therapy and progressive spinal deformity.

Kümmel's disease.

Kümmel's disease or Kümmel-Verneuil disease is a traumatic aseptic (non-microbial) inflammation of the vertebral body (spondylitis). The cause of this disease is vertebral trauma, which leads to the development of areas of necrosis in the vertebral body. The patient experiences pain in the area of ​​the injured vertebra, which goes away after 10-14 days. After this, a period of false prosperity begins, sometimes lasting up to several years. Then pain appears again in the area of ​​the injured vertebra. The patient may not remember the previous injury. The pain appears first in the spine, then radiates to the intercostal spaces. An X-ray examination reveals a wedge-shaped vertebra.

Treatment consists of unloading the spine. For this purpose, bed rest is prescribed for 1 month. The bed should be hard. A cushion is placed under the thoracic region. Then physiotherapeutic treatment and exercise therapy are prescribed.

Scheuermann-Mau disease.

Scheuermann-Mau disease, Schmorl's disease, chondropathic kyphosis, juvenile kyphosis, apophysitis of the vertebral bodies (inflammation of the places where muscles attach to the vertebra) or chondropathy of the apophyses of the thoracic vertebrae are different names for the same disease. With this disease, the 7-10 thoracic vertebrae are most often affected. The disease occurs in boys from 11 to 18 years old. The patient complains of back pain and fatigue of the back muscles with normal activity. On examination, increased thoracic kyphosis is detected (curvature of the spine in the thoracic region with a convexity posteriorly). X-rays reveal changes in the shape of the vertebrae. Normal vertebrae in the thoracic region look like bricks, with smooth edges. With Scheuermann-Mau disease, the vertebrae in the lower thoracic region become wedge-shaped.

Treatment consists of physical therapy, massage, underwater traction, and swimming. Occasionally, in cases of severe postural disorders, surgical treatment is used.

Forms of the disease

Doctors who diagnose Keller's disease define two types of disease, depending on which bones are affected.

If a person is diagnosed with Keller's disease 1 , then we are talking about damage to the navicular bone of the foot. This bone is located at the inner edge of the foot. Keller's disease 2 is manifested by pathological changes in the heads of the second and third metatarsal bones of the foot. These bones are connected by articular surfaces to the phalanges of the fingers. Stage 2 Keller's disease most often develops in adolescents.

In addition, when determining the symptoms that manifest osteochondropathy, doctors divide the course of the disease into several stages. At the stage of necrosis, the patient’s bone beams, which are the structural elements of the bones, die. Such changes are clearly expressed, they can be seen even in the photo. At the stage of a compression fracture , new elements of bone tissue are formed, but now they do not yet have sufficient strength. During this period, bone beams often cannot withstand heavy loads. As a result, their fractures occur, and the beams can wedge into each other. This is followed by the fragmentation stage , in which osteoclasts (those cells that destroy bone) promote the resorption of bone beams. The final stage of the disease is the process of restoring the shape and structure of the bone. The answer to the question of how to treat a disease directly depends on what stage of the disease is currently occurring. Therefore, treatment of Keller's disease can only begin after a thorough professional diagnosis.

What does treatment include?

Usually, conservative treatment allows you to achieve the desired result. The affected limb is unloaded, and immobilizing devices are used to immobilize it. If a fracture occurs, a plaster cast is applied to the limb, which must be worn without removal for an average of a month. After the plaster is removed, you will need to wear special orthopedic insoles, and in some cases, you will be prescribed the use of crutches for movement. Another important point is the correct selection of shoes - they should be orthopedic and not compress the arches of the feet. Special therapeutic exercises, physiotherapeutic procedures and massage have proven their effectiveness. During the rehabilitation period, it is imperative to avoid jumping and running - they can provoke the formation of cracks in the bones.

To quickly restore bone, the patient will need to take medications that improve metabolism and blood circulation. Vitamin complexes are prescribed, as well as drugs that activate phosphorus and calcium metabolism. Surgery is performed extremely rarely. They resort to it if conservative therapy does not produce the desired effect, and the pain syndrome is pronounced and cannot be relieved by drugs. The most common type of surgery is revascularization osteoperforation. Small cross-section channels are made into the bone, thanks to which its nutrition improves and it recovers much faster.

Without properly selected treatment, the duration of the disease increases significantly, and the shape of the bone changes. This leads to the development of foot deformities, in particular, flat feet. Contact Dr. Noah's clinic - diagnostics are carried out here using modern equipment and progressive treatment methods are practiced. This medical institution is one of the best in Germany. Each patient is guaranteed an individual approach and competent selection of treatment. The clinic is equipped with modern diagnostic equipment, operations are performed by leading specialists with many years of experience. You can trust the doctors of this clinic with the health of your child. If the above symptoms occur, do not delay treatment. Timely diagnosis and adequately selected treatment will allow you and your child to forget about the disease as soon as possible.

Symptoms

Keller's disease I is most often diagnosed in preschool boys aged 3 to 7 years. Initially, the child notices pain and signs of swelling on the back of the inner edge of the foot. Due to the pain, there is a constant limp in the child, who tries to lean on the opposite, outer part of the foot while walking. Typically, the disease affects only one foot. It lasts about a year, after which the pain gradually stops.

Keller II disease is most often diagnosed in teenage girls. It was first described by traumatologist Freiberg from the USA, and Keller studied this type of disease in more detail and gave its description. This form of the disease is often bilateral. As a rule, the onset of the disease goes unnoticed. Initially, pain develops in the area of ​​the head of the II or III metatarsal bones. They immediately appear in cases where a load is placed on the forefoot, and later the patient feels pain even at rest. The appearance of lameness is gradually noted, the patient cannot walk in shoes with thin soles, it is very difficult for him to walk barefoot, especially if the surface is uneven. Where the pathological process develops - on the dorsum of the foot - swelling appears. The finger that is located next to the head of the affected bone becomes shorter, and movements in the joint are limited. All these symptoms are present in the patient for about two years, after which the pain gradually begins to subside. However, if changes have occurred in the joint during this period, the pain may soon reappear. Sometimes familial cases of foot involvement are diagnosed. Most often, the disease is localized at the head of the second or third metatarsal bones, but damage to several bones rarely occurs.

Diagnostics

The doctor makes the diagnosis based on the results of a visual examination and radiographs of the feet. Based on the characteristic changes on x-rays, the orthopedist determines the type and stage of the disease.

• In the first stage of Keller's disease I, osteoporosis of the scaphoid bone is visualized radiographically, resulting from necrotic destruction of its spongy substance.
• Photographs taken later show compaction and flattening of this bone, with visible points of ossification.
• Even later images reveal the breakdown of the bone into separate fragments (defragmentation), due to the progression of necrosis. Signs of a fracture are visible.

In Keller II disease, the radiological signs of necrotic destruction are the same, only they are localized in the heads of the metatarsal bones of the toes.

Prevention

To ensure the right approach to prevention and prevent the development of both forms of Keller's disease, parents must, first of all, ensure that children always wear only comfortable and appropriately sized shoes. It is also important to reduce the mechanical load on the feet. To ensure that this condition is met, serious physical activity should not be allowed in preschool children. If you receive any foot injury, you must consult a doctor and undergo the tests prescribed by him. It is also important to pay attention to the presence of foot deformities and be sure to consult a specialist about this.

Summary

Although Keller's disease lasts for many months and sometimes with minimal symptoms, treatment should begin when its first signs appear. This will help avoid serious complications such as joint contracture, the development of osteoarthritis, worsening flat feet, and the formation of irreversible foot deformity due to a fracture of the scaphoid bone or its destruction.

Buying comfortable shoes of the right size, timely treatment of flat feet and pathologies of the endocrine system, and avoiding injuries will help prevent the occurrence of Keller's disease.

List of sources

• Traumatology and orthopedics / Guide for doctors: In 3 volumes T.Z / Ed. SOUTH. Shaposhnikova. -M.: Medicine, 1997.
• Movshovich I.A. Operative orthopedics. M.: Medicine. 1994;
• Sorokin, S.A. Diagnosis of the second Köhler disease / S.A. Sorokin // Restorative treatment of children with diseases and injuries of the musculoskeletal system: collection. scientific tr. / ed. B.L. Andrianova. - St. Petersburg, 1991.
• Traumatology and orthopedics. Multi-volume guide for doctors. Ed. N.V. Kornilov. SPb.: Hippocrates. 2006; III;
• Varshavsky G.I. On the differential diagnosis of Keller II disease / G.I. Varshavsky, I.M. Varshavsky // Annals of Traumatology and Orthopedics. 1994. -№2;