Freiberg's

Definition

 

Crushing osteochondritis of metatarsal head

 

Frieberg's

 

Epidemiology

 

Usually 2nd metatarsal (80%)

- occasionally third

- can occur in any

 

Age 10-15 years

- peak 15 year old girls

- F:M = 3:1

- occurs during the growth spurt at puberty

 

Bilateral in 6%

 

Aetiology

 

Trauma / repetitive stress

- interrupts blood supply to epiphysis

- fragmentation and AVN

 

2nd MT prone to stress fracture & AVN

- long MT

- fixed base

- thin shaft

 

Pathology

 

Ischaemic necrosis of epiphysis

 

Commonly have synovitis as well

 

Clinical

 

Tender enlarged MT head

- pain on dorsiflexion

- limited dorsiflexion due to synovitis or degenerative change

 

DDx

 

MTPJ synovitis / arthritis / synovial cyst

Interdigital neuroma

Stress fracture

 

X-ray

 

Enlarged flattened MT head

- widened joint space

- osteolysis & collapse in late stages

 

Leads to MTPJ OA

 

MRI

 

Friebergs MRIFriebergs MRI

 

Classification Smillie 

 

Stage I 

 

Subchondral fissure in epiphysis

 

Xray normal

Bone scan / MRI positive

 

Stage II 

 

Collapse of dorsal central portion of MT head

 

Xray

- slight widening of joint space

- sclerosis of epiphysis

 

Stage III 

 

Friebergs Stage III

 

Xray

- progressive flattening of the head / osteolysis / collapse

 

Stage IV 

 

Xray

- fragmentation of epiphysis

- multiple loose bodies

 

Stage V 

 

Friebergs Stage V

 

Xray

- advanced degenerative arthrosis

- joint space narrowing

- hypertrophy of MT head

- osteophyte formation 

 

MRI

 

 

Management

 

Non-operative

 

Algorithm

 

Limit activities 6/52

Metatarsal bar / preMT dome to unload MT head

Avoid high heels

Consider POP / moonboot to reduce symptoms

 

Operative 

 

Options

 

Synovectomy & joint debridement / removal of loose bodies

 

Indication

- stage II / III disease

 

Osteophyte removal / Cheilectomy

 

Closing wedge extension osteotomy

 

Concept

- dorsiflexion osteotomy

- most affected portion MT head is dorsal

- redirects plantar articular surface

 

Excision of MT head 

 

Indication

- severe disease

 

Issue

- not a great operation 

- associated with hallux valgus and transfer metatarsalgia