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Ankle Specialist

Freiberg's Infraction: Diagnosis and Treatment

Paul G. Talusan, Pablo J. Diaz-Collado and John S. Reach, Jr.
Foot Ankle Spec published online 5 December 2013
DOI: 10.1177/1938640013510314

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research-articleXXXX
FASXXX10.1177/1938640013510314Foot & Ankle SpecialistFoot & Ankle Specialist

vol. XX / no. X Foot & Ankle Specialist 1

〈 Review 〉
Freiberg’s Infraction Paul G. Talusan, MD, Pablo J. Diaz-
Collado, MD, and John S. Reach Jr., MD,

Diagnosis and Treatment MSc

Abstract: Freiberg’s infraction is a sufficiently to prevent its occurrence. Pathophysiology

condition of cartilage degeneration of Outcomes of nonoperative and
The pathophysiology of this condition
the lesser metatarsal heads. Adolescent operative management are good to
is unknown. Most authors suggest a
females are the “textbook” patients but excellent and most patients are able to
multifactorial etiology combining trauma,
both males and females may present return to previous activity.
vascular, genetic, and altered
with this condition later in life. The
Levels of Evidence: Therapeutic, biomechanics. The skeletal maturation
second and third metatarsals are
Level IV process may also contribute to the
the most commonly affected, while
development of Freiberg’s infraction and
involvement of the fourth and fifth is
Keywords: Freiberg; infraction; may provide insight into why adolescents
rare. The incidence is higher in females
metatarsal; osteotomy are affected more than adults.5 Injection
than in males. The pathophysiology
studies by Petersen et al6 suggest
is unknown, but studies suggest a
vascular injury to the dorsalis pedis
combination of vascular compromise, Introduction artery and 2 plantar metatarsal arteries
genetic predisposition, and altered
In 1914, Freiberg1 described a originating from the posterior tibial artery

“
biomechanics. Diagnosis is made
condition in 6 patients
clinically and imaging is used
with pain over the
to confirm. Early in the process,
second metatarsal While the cause of Freiberg’s
radiographs are normal however during activity.
bone scans may demonstrate a Radiographs revealed a infraction has been elusive, gross
photopenic center with a hyperactive sclerotic and flattened
collar and magnetic resonance metatarsal head.1 He descriptions at the time of surgery have
imaging can reveal hypointensity of attributed this condition
the metatarsal head. As Freiberg’s to either a traumatic
been consistent throughout the
infraction progresses, radiographs
show a flattened and fragmented
incident or repetitive literature.”
trauma but in a later
metatarsal head. Nonoperative publication suggested
treatment is based on decreasing foot that trauma alone may not be sufficient may compromise the extraosseus arterial
pressure and unloading the affected to cause this lesion.2 The most affected network around the metatarsal head.
metatarsal. Spontaneous healing with metatarsals are the second and third While the cause of Freiberg’s infraction
remodeling may occur in early stages while the fourth and fifth metatarsals has been elusive, gross descriptions at
of the disease. Operative options are are rarely affected.3 There have not the time of surgery have been consistent
dorsal closing wedge osteotomies, been any studies examining the throughout the literature. Deformation of
osteochondral transplant, and incidence of Freiberg’s infraction but the dorsal articular surface of the
resection arthroplasty. Currently, Katcherian4 calculated a female to male metatarsal head followed by loosening
we do not understand this disease ratio of 5:1. and destruction of 30% to 50% of the

DOI: 10.1177/1938640013510314. From the Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut. Address
correspondence to John S. Reach Jr. , MD, MSc, Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, 1st Floor, New
Haven, CT 06520; e-mail: john.reach@yale.edu.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2013 The Author(s)

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2 Foot & Ankle Specialist Mon XXXX

Stage 4: Articular surface has sunk so

Figure 1. far that restoration of normal
Smillie’s classification. Stage 1: Fissure in epiphysis with sclerosis between anatomy has passed. Fractures of
cancellous surfaces. Stage 2: Absorption of cancellous tissue on the proximal side the medial and lateral projections
with sinking of the articular cartilage dorsally. Stage 3: Further absorption and may occur.
sinking of the articular surface with bony projections medially and laterally. Stage 4: Stage 5: Arthrosis with flattening and
Articular surface has sunk so far that restoration of normal anatomy has passed. deformity of the metatarsal head.
Stage 5: arthrosis with flattening and deformity of the metatarsal head. (Courtesy of The plantar aspect is the only area
Smillie IS. Treatment of Freiberg’s infraction. Proc R Soc Med. 1967;60(1):29-31. where cartilage retains its original
Published by SAGE Pub.) contour. The shaft of metatarsal is
thickened and dense.10

Gauthier and Elbaz3 also proposed a

5-part classification. In their scheme, they
postulated subchondral bone fatigue
fracture to be the initial lesion leading to
necrosis by the absence of vascular
connections. Lesions can evolve from
stage 0 to stage 4 or may consolidate and
heal at any stage. If consolidation occurs
in stage 0 or 1, consolidation without
sequelae may occur. Stage 2 leaves the
metatarsal head flattened. Stage 3 results
in irreparable damage and leading
directly to arthrosis.3

Stage 0: Subchondral bone fatigue

articular surface is typical. The plantar
articular surface is invariably intact.7,8
Braddock5 performed an autopsy study
on second metatarsals from 9 children
and 4 adults who died of acute illness or
accident and found that the distal
metatarsal metaphysis is weakest in
11- to 12-year-olds. They used an
apparatus to deliver predictable force to
the metatarsophalangeal joint. The
proximal phalanx fractured in all cases
except for those in the 11- to 12-year
age-group where the distal metatarsal
failed.5 Although no genetic studies have
been performed to evaluate a hereditary
disposition for Freiberg’s infraction, twin
studies suggest a genetic predisposition
for this malady.9
Altered foot biomechanics may also
play a part. The study by Gauthier and
Elbaz3 of 79 cases of Freiberg’s infraction
noted that 42 of the patients had hallux
valgus. Shifts in weight-bearing stress
fracture with normal radiograph
Stage 1: Osteonecrosis without
deformation
Stage 2: Deformation by crushing of
osteonecrosis
from the first ray to adjacent metatarsal Stage 3: Gradual cartilaginous tearing
heads may lead to overload and Stage 4: Arthrosis3
infraction.3
Freiberg’s infraction is typically
diagnosed clinically and confirmed with
Classification and Imaging plain films. Bone scans and magnetic
The most widely used classification of resonance imaging (MRI) may be useful
Freiberg’s infraction is that of Smillie.10 early in the disease process before
Five stages of metatarsal head radiograph changes are evident.
degeneration were described (Figure 1). Ultrasound is an imaging tool to evaluate
cartilage and bone loss in this disease.
Stage 1: Fissure in epiphysis with Mandell and Harcke11 used bone scans
sclerosis between cancellous and showed how early disease
surfaces. demonstrates a photopenic center with
Stage 2: Absorption of cancellous hyperactive collar suggesting avascular
tissue on the proximal side with necrosis. Advanced disease demonstrates
sinking of the articular cartilage diffuse hyperactivity on scintiscan
dorsally. secondary to revascularization and
Stage 3: Further absorption and repair.11
sinking of the articular surface with Magnetic resonance imaging can be an
bony projections medially and early detector of progressive disease.
laterally. There is exostosis on the Harilainen et al12 published a case report
dorsal proximal metatarsal head. in a 12-year-old female with 6 weeks of

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vol. XX / no. X Foot & Ankle Specialist 3

forefoot pain and tenderness over the

second metatarsal. Radiographs were Figure 2.
normal and an MRI revealed (A) Preoperative radiograph of a 40-year-old woman with second
hypointensity of the second metatarsal metatarsophalangeal pain. There is slight flattening of the metatarsal head. (B)
head. Seven months later, repeat Radiograph six months following dorsal closing wedge metatarsal head osteotomy
radiographs revealed significant with snap-off screw fixation. (Both figures A and B courtesy of Talusan PG, Perez
progression with a flattened, condensed, JL, Reach JS Jr. Freiberg infraction. In: Alexander IJ, Bluman EM, Greisberg J
fragmented metatarsal head.12 (eds): Advanced Reconstruction Foot & Ankle 2. Published by American Academy of
Orthopaedic Surgeons. In press.)24
Nonoperative Treatment
Nonoperative management is rooted in
decreasing foot pressure and unloading
the affected metatarsal. Smillie10 reports
that spontaneous healing may occur at
any stage and restoration of a normal
metatarsal head may be possible in stage
1 to 3. Stage 4 and after fracture of the
isthmus occurs, “perfection or anything
resembling perfection is unobtainable.”10
To our knowledge, there have not been
any trials of nonoperative techniques.
Reports in the literature describe stiff-
soled shoes, casting, and orthotics.
Palamarchuck and Oehrlein13 reported a
collegiate heptathlete with Freiberg’s
infraction who was able to compete
using a custom orthosis.

Operative Treatment
Freiberg’s classic article described
successful intervention with
metatarsophalangeal joint arthrotomy
and debridement with removal of loose
bodies. Smillie10 predictably based his
treatment on stage of disease. The goal
of treating stages 1 and 2 disease was to
establish blood supply of the metatarsal
head by breaking down sclerosis,
excising fibrous tissue, and obliterating
the epiphyseal plate with a gouge. Stage
3 disease was his last stage for reparative
measures, as he found the head
deformed and loose bodies present.10
Gauthier and Elbaz3 described a closing
wedge dorsiflexion osteotomy of the
metatarsal head in 53 cases of Freiberg’s
infraction. The wedge of necrotic dorsal
head is excised and the healthy plantar
aspect of the metatarsal head is rotated
dorsally to replace the necrotic segment.3
At 22 months postoperatively, only 1 of
the 53 patients had continued pain and
he reported that there were no
complications3 (Figure 2). Kinnard and
Lirette14 performed a similar operation in
10 cases and initially used cerclage wires
for fixation. After patients predictably
complained of tendinitis, they switched
to absorbable suture. All patients were
able to return to sports and there were
no cases of transfer metatarsalgia.14
Dorsal closing wedge osteotomies with
crossed Kirschner wire fixation is also
popular and successful.7,8,15-17
Some authors have developed other
techniques in an attempt to improve
fixation constructs. Smith et al18
advocated a procedure that did not
involve an arthrotomy. They performed a
dorsal closing wedge osteotomy of the
metatarsal neck and fixed the fragments
using a T-shaped plate. At 4.9 years
average follow-up, they had a 94% good
to excellent outcome. There was an
average shortening of 4 mm of the
metatarsal.18
To address the disadvantages of
Kirschner wire and plate fixation, Lee et
al19 used three to four 1.5-mm
bioabsorbable pins. Radiographic healing
was achieved at 10 weeks postoperatively
with an average metatarsal shortening of
1.7 mm. All patients returned to full
recreational activities by 4 months. In
their study, there were no cases of
foreign body reactions.19
Recently, osteochondral transplant for
the treatment of symptomatic Freiberg’s
infraction has been advocated. Miyamoto
et al20 and Hayashi et al21 used the
non-weight-bearing ipsilateral lateral
femoral condyle donor site and
transplanted this to the diseased portion
of the metatarsal head. In both series,
good results and low donor site
morbidity was reported.20,21
Authors’ Preferred Treatment
The authors’ preferred treatment for
symptomatic Freiberg’s infraction begins
with a thorough workup for causes of
osteonecrosis (steroids, rheumatoid

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4 Foot & Ankle Specialist Mon XXXX

vascular compromise, genetic

Figure 3. predisposition, and altered biomechanics
(A) Dorsal approach to the metatarsal head is made. Freiberg lesion is seen on are likely responsible.3,5,6,9
the dorsal second metatarsal head. (B) A closing wedge osteotomy is made Freiberg’s infraction is a clinical
on the dorsal metatarsal head. (C) The Freiberg lesion is removed. (D) The diagnosis and imaging is used for
plantar articular surface is rotated dorsally and secured using Kirschner wires confirmation. Radiographs are normal
or snap-off screws. (Figures A-D, courtesy of Talusan PG, Perez JL, Reach JS early in the disease process; however,
Jr. Freiberg infraction. In: Alexander IJ, Bluman EM, Greisberg J, eds. Advanced bone scans11 and MRI can be helpful.12
Reconstruction Foot & Ankle 2. Published by American Academy of Orthopaedic The goal of nonoperative treatment is
Surgeons. In press.)24 to decrease foot pressure and unload the
affected metatarsal. Healing and
remodeling may occur in the early
stages.10 Operative options are dorsal
closing wedge osteotomies,
osteochondral transplant, and resection
arthroplasty.
Currently, we do not understand this
disease process sufficiently to prevent its
occurrence.

arthritis, coagulopathy). A trial of anti-
inflammatory medications and a stiff-
soled orthotic to decrease motion at the
metatarsophalangeal joint is attempted
for a period of 3 months.
If patients continue to have pain
despite non-operative efforts, surgical
treatment is pursued. The author’s
preferred method is a closing wedge
osteotomy with the patient in the supine
position and a tourniquet on the thigh or
leg. A dorsal approach to the metatarsal
head is used and a closing wedge
osteotomy is performed after a
longitudinal capsulotomy. The amount of
resected head depends on the extent of
disease, and the goal is to rotate enough
of the plantar surface of the metatarsal
head to articulate with the proximal
phalanx. Fixation is achieved using a
fully threaded snap-off screw from dorsal
to plantar. The wound is then irrigated
and closed with interrupted nylon
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