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Remote Fellowship – Foot & Ankle Fundamentals – 11/2/2020

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Diagnosis

Freiberg’s Infraction

Case Discussion

Freiberg’s infraction is osteochondrosis of the lesser metatarsal heads. The second and third metatarsals are the most commonly affected, and the disease has a higher incidence in females than in males. Patients typically present with pain at the level of the metatarsophalangeal joints that is made worse with weight bearing. The exact etiology is unknown, however, it is thought to be from repetitive microtrauma to the metatarsal head. This may be secondary to activities such as dancing or jogging, or secondary to the structure/biomechanics of the foot (e.g., a short first metatarsal and/or long 2nd metatarsal).

MRI findings of Freiberg’s infraction depend on the acuity of the disease. Early-stage findings include osteoedema manifesting as low signal intensity on  T1 weighted images, and increased signal intensity on T2 weighted and STIR images. Late-stage findings include sclerosis (seen as low signal on T1 and T2 images), metatarsal head flattening/deformity and fragmentation.

Key Images

Freiberg’s infraction in a 45-year-old woman with a history left 2nd toe injury 6 months prior, now complaining of pain in the same toe.

A. Sagittal T1 image of the left foot shows mild flattening of the 2nd metatarsal head (red arrow) with surrounding subchondral low signal osteoedema/early sclerosis.
B. Sagittal STIR image shows extensive osteoedema and mild flattening of the second metatarsal head (red arrow) and moderate reactive capsulitis in the 2nd metatarsophalangeal joint (green arrow).
C. Axial T1 image shows subchondral low signal intensity with mild flattening of the 2nd metatarsal head (red arrow).

References

  1. Torriani M, Thomas BJ, Bredella MA, Quellette H. MRI of metatarsal head subchondral fracture in patients with forefoot pain. American Journal of Roentgenology 2008; 190:570-575