Updated: 10/6/2016

Freiberg's Disease

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  • A condition characterized by infarction and fracture of the metatarsal head.
    • also known as Freiberg's infraction 
  • Epidemiology
    • demographics
      • female to male  = ~ 4:1
      • most commonly seen in patients 13-18 years
      • more common in female adolescent athletes
    • body location
      • most often seen in 2nd metatarsal (MT) head, particularly the dorsal aspect
      • 4th and 5th MT rarely affected
    • risk factors
      •  more common in patients with long 2nd metatarsals
  • Pathophysiology
    • thought to be related to a disruption in the blood supply due to microtrauma or osteonecrosis and stress overloading
      • leads to eventual collapse of 2nd MT head
Smillie Classification
Stage 1 Subchondral fracture visible only on MRI  
Stage 2 Dorsal collapse of articular surface on plain radiographs
Stage 3 Collapse of dorsal MT head, with plantar articular portion intact  
Stage 4 Collapse of entire MT head, joint space narrowing   
Stage 5 Severe arthritic changes and joint space obliteration  
  • Symptoms
    • forefoot pain, swelling and stiffness localized to head of the second MT
      • worse with weight bearing activities
  • Physical exam
    • inspection
      • peri-articular swelling
    • motion
      • exacerbated by distraction (early stages) and compaction (later stages)
      • limitation of motion in 2nd MTP joint
  • Radiographs 
    • recommended views
      • AP, lateral, obliques of foot
    • findings (see Smillie classification)
      • subchondral sclerosis in early disease 
      • flattening of involved MT head 
      • joint destruction in late disease  
      • defect is usually located in the upper half of the articular surface of the MT head
  • MRI 
    • findings
      • can show patchy edema in metatarsal head 
  • Nonoperative
    • activity limitations, NSAIDS, immobilization
      • indications
        • early stage of disease
      • technique
        • short leg walking cast or boot for 4-6 weeks
          • can be used if symptoms are severe and do not improve with orthotics
        • stiff-soled shoe with MT bars or pads
          • typically used after period of casting
  • Operative
    • metatarsophalangeal arthrotomy with removal of loose bodies
      • indications
        • very rarely indicated
        • only if extensive nonoperative management fails
    • dorsal closing-wedge osteotomy 
      • indications
        • dorsal disease involvement of bone and cartilage
    • DuVries arthroplasty (partial MT head resection)  
      • indications
        • severe stage 4 or 5 disease
        • plantar cartilage is not sufficient to reconstruct joint
        • can consider adding capsular interposition after joint debridement
  • Metatarsophalangeal arthrotomy with removal of loose bodies
    • approach
      • lesser toe MTP joint approach 
    • technique
      • may be combined with drilling of metatarsal head, subchondral bone grafting, and interposition arthroplasty using EDL tendon
      • metatarsal head resection should be avoided due to increased loads on adjacent metatarsal heads
  • Dorsal closing-wedge osteotomy
    • goals
      • shortening offloads stress on metatarsal head
      • resects collapsed dorsal diseased bone and cartilage
    • approach
      • lesser toe MTP joint approach 
    • technique
      • bring less affected plantar cartilage into contact with proximal phalanx
  • Degenerative joint disease
    • of 2nd MTP joint in adulthood


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