FREIBERG'S DISEASE

LAURA E. ROSS, D.O., Resident, Orthopaedic Surgery

WILLIAM,G. MACKENZIE, M.D., Attending Pediatric Orthopaedic Surgeon

December 14, 1995

CLINICAL CASE PRESENTATION

ORTHOPAEDIC DEPARTMENT

THE ALFRED I. DUPONT INSTITUTE

WILMINGTON, DELAWARE

CASE HISTORY:

• HISTORY: 15 + 4 year old female with left foot pain near the fourth toe for one year. She had no antecedent trauma. She described her pain as a constant, dull ache which had been getting progressively worse.
• PHYSICAL EXAM: She complained of exquisite tenderness with flexion and extension of her left fourth toe. She had tenderness to palpation over the dorsum of the fourth metatarsal phalangeal joint. She was unable to toe walk without inverting her foot to releive pressure from the fourth metatarsal head. There were no other significant physical findings.
• RADIOGRAPHS: Radiographs revealed flattening of the metatarsal head and joint space narrowing.
• ASSESSMENT: Freiberg's disease of the left fourth metatarsal head
• PLAN:
1. Firm orthothotic with a metatarsal bar
2. NSAID
3. Hard sole shoe
4. F/U in 4 weeks

FREIBERG'S DISEASE

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.

REFERENCES:

1. Binek,R. et al. Freiberg Disease Complicating Unrelated Trauma. Orthopedics 11:5. pp.753-57. 1988.
2. Canale, S. and Beaty,J. Operative Pediatric Orthopedics. St. Louis,MO, Mosby I 995. 2nd edition. pp.844-46.
3. Drennan, J. The Child's Foot and Ankle. New York,NY, Raven Press, 1 992. p. 102, pp.412-13. Mann, Roger. Surgery of the Foot and Ankle. St. Louis,MO, Mosby,1993. pp.435-39.
4. Meehan, Peter. Chapter 3 1. Lovell and Winter's Pediatric Orthopaedics. Philadelphia,PA, J.B. Lippincott,1990. 3rd edition. pp. 1007-8.
5. Sproul,J. et al. Surgical Treatment of Freiberg's Infraction in Athletes. American Journal of Sports Medicine. 21:3. pp.381-4. 1993.