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Freiberg Disease Workup

  • Author: Shayne D Fehr, MD, FAAP; Chief Editor: Jason H Calhoun, MD, FACS  more...
 
Updated: Mar 24, 2015
 

Laboratory Studies

On the basis of the clinical presentation and imaging findings, laboratory studies and other investigations may be indicated to rule out other etiologies of pain or deformity. In particular, infectious and oncologic processes may cause pain and abnormal imaging of the metatarsal head.

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Imaging Studies

Radiography

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. Osteochondral loose bodies may be seen late in the disease as well. Oblique views may be especially useful to fully appreciate subtle changes early in the disease. One study advocates the use of radiographs to assess musculoskeletal foot conditions in women related to poorly fitting shoes.[22]

Occasionally, patients are completely asymptomatic, with changes noted on radiographs taken for other reasons. Whether these patients later develop symptomatic Freiberg disease is not known.

Advanced imaging

The use of bone scanning 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.[4]

magnetic resonance imaging (MRI) is helpful in detecting early Freiberg disease not visualized on plain radiographs.[23] MRI may demonstrate hypointense signal in the epiphysis on T1 images and mixed hypointense and hyperintense signals on T2 images. Flattening of the metatarsal head may be identified as well.[7]

MRI has been advocated by some physicians as helpful for preoperative evaluation, especially if an osteotomy is planned. One study demonstrated that three-dimensional (3D) CT scans were useful in characterizing the extent of osteonecrosis in a lesion.[24]

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Histologic Findings

Histologic examination of tissue from resected specimens has produced varied findings. Different studies have found bone resorption and new bone formation, depending on the stage of the disease.[25]

Young et al described separation of the deeper layers of the hyaline cartilage in a 55-year-old man with Freiberg disease.[26] The separation had occurred in close proximity to the zone of mineralization, and avascularity was not evident. The authors concluded that in this one case, a traumatic shear or compression-type injury was likely to have been responsible, as opposed to some type of vascular insult (avascular necrosis).

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Staging

Several staging schemes 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 five stages[27] (see the images below):

  • 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 - This 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
    Early stage I-II lesion of Freiberg disease, best Early stage I-II lesion of Freiberg disease, best seen on oblique radiograph.
    Stage III Freiberg disease with advanced flattenin Stage III Freiberg disease with advanced flattening.
    Stage IV Freiberg disease with articular collapse Stage IV Freiberg disease with articular collapse and loose body formation.
    Stage V Freiberg disease with advanced degenerativ Stage V Freiberg disease with advanced degenerative changes involving metatarsal head and proximal phalanx.
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Contributor Information and Disclosures
Author

Shayne D Fehr, MD, FAAP Assistant Professor, Department of Orthopaedic Surgery, Medical College of Wisconsin; Consulting Staff, Sports Medicine and Concussion Clinics, Children's Hospital of Wisconsin

Shayne D Fehr, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Kevin D Walter, MD, FAAP Associate Professor, Department of Orthopaedic Surgery, Medical College of Wisconsin; Program Director, Children's Hospital of Wisconsin Pediatric and Adolescent Primary Care Sports Medicine

Kevin D Walter, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Michigan State Medical Society, Missouri State Medical Association, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, Texas Orthopaedic Association, Musculoskeletal Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

John S Early, MD Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center

John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Medical Association

Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.

Acknowledgements

Matison Boyer, MD  Consulting Surgeon, Department of Orthopedic Surgery, Orthopaedic Specialists of Charleston

Matison Boyer, MD, is a member of the following medical societies: American Medical Association, American Orthopaedic Foot and Ankle Society, and South Carolina Medical Association

Disclosure: Nothing to disclose.

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD, is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society

Disclosure: Nothing to disclose.

The authors would like to acknowledge Scott E Van Valin, MD, Assistant Professor, Department of Orthopaedic Surgery, Medical College of Wisconsin, and Roger M Lyon, MD, Professor, Department of Orthopaedic Surgery, Medical College of Wisconsin, for their contributions in the review of surgical content.

References
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Early stage I-II lesion of Freiberg disease, best seen on oblique radiograph.
Stage III Freiberg disease with advanced flattening.
Stage IV Freiberg disease with articular collapse and loose body formation.
Stage V Freiberg disease with advanced degenerative changes involving metatarsal head and proximal phalanx.
 
 
 
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