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Quiz Prize Rules Current Rankings Freiberg Infraction
The MRI shows a subchondral area of altered signal with a hypointense crescentric line / fracture in the 2 nd distal metatarsal head. The CT scan (Fig. 5) shows similar changes. These features are suggestive of an osteochondral lesion of the 2 nd metatarsal head and are characteristic of Freiberg infraction.Synonyms and related keywords include infraction of the metatarsal head, osteochondrosis of the metatarsal heads, avascular necrosis of the metatarsal head, eggshell fracture, peculiar metatarsal disease, Koehler second disease, Panner disease of the metatarsals, osteochondritis deformans metatarso-juvenilis, malacopathia, subchondral bone fatigue fracture of the metatarsal head, dorsal trabecular stress injury of the metatarsal head.
In his original description, Freiberg favored a traumatic etiology; however, he later admitted that trauma itself could not reliably explain all cases. Despite several thoughtful investigations into the etiology of Freiberg disease, no consensus exists as to what type of disease process this peculiar affliction represents. This lack of consensus is reflected in the numerous terms used in the literature to describe this process.
Freiberg disease in adolescents is thought to belong to a group of related diseases involving growth disturbances of the epiphysis or apophysis, collectively termed the osteochondroses. Of all the osteochondroses, Freiberg disease is reported to be the fourth most common, exceeded by Köhler disease of the tarsal navicular, Panner disease of the capitellum, and Sever disease of the calcaneus.
Some authors, however, favor trauma as the predominant etiologic agent in the development of Freiberg disease. This may be in the form of a single acute injury or multiple repetitive microinjuries. Various authors have suggested that altered kinematics around the forefoot may predispose some patients to injury as a result of abnormal loading and may ultimately contribute to the development of Freiberg disease.
Clinical Diagnosis
The diagnosis of Freiberg disease is relatively straightforward when patients present with the typical complaints of activity-related forefoot pain with passive motion of the MTP joint and pain with palpation over the metatarsal head. The differential diagnoses may include metatarsalgia, Morton neuroma, stress fracture of the metatarsal, and synovitis.
History
Patients typically present with pain, stiffness, and a limp. History of trauma may or may not exist. The pain is often vague, related to activity, and poorly localized to the forefoot. Patients may describe a chronic history of forefoot pain with episodic exacerbation or a sudden onset of pain related to a specific injury
Staging
Several staging systems have been described. Most are based on radiographic appearance, including the amount of collapse and the presence or absence of secondary degenerative changes. The classification scheme developed by Smillie in 1967 is the most often quoted system and divides the radiographic changes into the following 5 stages:
- Stage I - The earliest sign is fissuring of the epiphysis. Radiographic changes at this stage may be so subtle that they are missed with routine radiographs.
- Stage II - Later central depression of the articular surface becomes evident as subchondral cancellous bone is resorbed. The articular cartilage hinges on an intact plantar bridge.
- Stage III - The central depression is seen to be resulting in medial and lateral projections at the margins. The plantar hinge remains intact at its plantar isthmus.
- Stage IV - This stage demonstrates that the central portion has sunk below the surface and is free of the plantar hinge, thus becoming a loose body. Fractures of the medial and lateral projections are present, with folding of the projections over the central loose body.
- Stage V - The final stage shows marked flattening and deformity of the metatarsal head with secondary degenerative changes. The central loose body may have been resorbed at this stage. The shaft of the metatarsal becomes thickened and dense.
Imaging Studies
- Radiographs
- Depending on the stage of the disease, radiographs may show only sclerosis and widening of the joint space (early), with complete collapse of the metatarsal head and fragmentation later.
- Oblique views may be especially useful to fully appreciate subtle changes early in the disease.
- Osteochondral loose bodies may be seen late in the disease as well.
- The use of bone scintigraphy has been described with photopenia in the early stages of the disease, with intense uptake later as the head is reconstituted or revascularized. Although bone scintigraphy has been used in the study of Freiberg disease, its value as a diagnostic or prognostic tool is unknown.
- Magnetic resonance imaging (MRI) has been advocated by some physicians as helpful for preoperative evaluation, especially if an osteotomy is planned.
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PubMed References for Freiberg Infraction
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