LAURA E. ROSS, D.O., Resident, Orthopaedic Surgery
WILLIAM,G. MACKENZIE, M.D., Attending Pediatric Orthopaedic Surgeon
December 14, 1995
CLINICAL CASE PRESENTATION
THE ALFRED I. DUPONT INSTITUTE
Freiberg first described this entity in 1914 in six patients as an infraction (incomplete fracture without displacement of the fragments). It is more commonly seen in females, usually in the second decade. Unilateral involvement of the second metatarsal is the most common presentation, however it may occur in the third and more rarely the fourth and fifth metatarsals.
There is some controversy as to the etiology, as it is unclear as to whether this is a result of trauma or primary avascular necrosis of the metatarsal head.
Clinical Presentation and Findings: Forefoot pain, especially at the extremes of joint motion, is the chief complaint. It is primarily associated with running, but later with walking or standing. There is usually localized tenderness to palpation. They may develop painful callosities under adjacent metatarsal heads. Stiffness in the involved joint may be present.
Radiographic Findings: In the early phase, subchondral fractures may be present. As the disease progresses, resorption of the necrotic bone occurs, with epiphyseal fracture. Finally, there is flattening of the metatarsal head with severe deformity. Varying degrees of thickening of the metatarsal shaft may be present, representing the response to abnormal stress along the metatarsal.
Treatment: Early in the disease process, short term immobilization in a plaster cast is indicated. In later stages, a metatarsal pad or bar inserted proximal to the MTP joint may be utilized. This should be continued during athletic activities until the epiphysis closes. NSAIDS may help relieved discomfort from periarticular tissue swelling. Surgical treatment is not indicated in the child unless symptoms persist after ceasing athletic activity, conservative treatment fails, or radiographs reveal an incongruent joint with a deformed metatarsal head.
Surgical procedures for Freiberg's disease include the following: (1) debridement of the metatarsal with removal of loose bodies, (2) dorsiflexion osteotomy of the distal metatarsal, and (3) shortening osteotomy of the metatarsal. Resection of the metatarsal head should not be performed because of the complications of hallux valgus and adjacent metatarsalgia.