*68-year-old female with pain and swelling at the forefoot for 2 years.
What is the most likely diagnosis?
Answer
Answer: Freiberg disease
Case Discussion:
Plain radiograph revealed flattening of the second metatarsal head (arrows).
MR images showed irregularity-flattening of the second metatarsal head, edema in the metatarsal head-shaft, metatarsophalangeal joint effusion, capsular thickening, and soft tissue edema.
Freiberg disease (also known as Freiberg infraction) is the painful collapse of the articular surface of the second metatarsal head. Clinical presentation is pain, swelling and tenderness. It can occur at any age, with an age range of 8-77 years reported in the literature. Male to female ratio is 1:3. Histologically, it is characterised by collapse of the subchondral bone, osteonecrosis, and cartilaginous fissures.
Plain radiograph
Early signs are sclerosis of the second metatarsal head and widening of joint space. Late signs are fragmentation, collapse, and flattening of metatarsal head.
MRI
Early signs include low-signal-intensity changes in the second metatarsal head on T1WI with increased signal intensity on corresponding T2WI and STIR image. With disease progression, flattening of the second metatarsal head occurs, and low-signal-intensity changes develop on T2WI as the bone becomes sclerotic.
References:
1.Freiberg AH. Infraction of the second metatarsal bone, a typical injury. Surg Gyn Ob. 1914. 19:191.
2. Ashman CJ, Klecker RJ, Yu JS. Forefoot pain involving the metatarsal region: differential diagnosis with MR imaging. Radiographics. 21 (6): 1425-40.
3. Torriani M, Thomas BJ, Bredella MA et-al. MRI of metatarsal head subchondral fractures in patients with forefoot pain. AJR Am J Roentgenol. 2008;190 (3): 570-5. doi:10.2214/AJR.07.2847 – Pubmed citation