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Avascular Necrosis of Bone (Freiberg’s Infraction)

The Condition

Patients with Freiberg’s infraction typically present with complaints of activity-limiting pain at the ball of the foot. This condition most frequently affects the second metatarsal head where it meets the base of the 2nd digit. Swelling and warmth of the forefoot tissue is frequently encountered. Symptoms may begin spontaneously or may occur following a specific trauma to the area. The condition can limit forefoot motion, resulting in a limp.

The Treatment

Treatment includes the early identification and immobilization of the injured bone. The effects of forefoot pressure and shock experienced with physical activity must be neutralized. Trauma will result in additional damage and deformation of the bone and joint. Patients identified as having more advanced stages of this disease may require surgery to improve joint function and restore anatomy.

Frequently Asked Questions

Females are five times more likely to develop this condition than their male counterparts. Affected individuals range in age from adolescence through the second decade of life. However, Freiberg disease can occur at any age.
Any of the metatarsal bones may be involved. It is very rare to have multiple bones affected by this problem. In more than 95% of cases the damage is found in the second or third metatarsal, with the second metatarsal being affected with greater frequency.
A detailed medical history and physical examination of the foot is necessary. Plain film radiographs (X-rays), magnetic resonance imaging (MRI) and computerized tomography scan (CT) are typically used to appreciate the extent of the damage.
A non-weightbearing cast may be required to provide sufficient relief. For some, a short leg walking cast-boot or hard-sole shoe may be more appropriate. Typically, the period of immobilization lasts approximately 4-6 weeks. Steroid injections, nonsteroidal anti-inflammatory drugs (NSAIDs), ultrasound, bone stimulator, and physical therapy are sometimes prescribed to help reduce painful symptoms. Steroids and NSAIDs can slow healing and must be used cautiously.
Surgical options vary depending upon the severity of bone and joint damage sustained. Joint debridement is a method used to remove loose and fragmented portions of the damaged tissue. Bone grafting techniques may be used to restore anatomy. Osteotomies are performed to redirect the loading of the metatarsophalangeal joint (MTPJ) away from the damaged area of the joint surface. Other options include joint arthroplasty with hemi-joint replacement to regain the joint surface and contour.