What is the initial treatment for a suspected Freiburg infraction?

Initial Treatment for Suspected Freiberg Infraction

The initial treatment for a suspected Freiberg infraction should involve non-operative management focused on decreasing foot pressure and unloading the affected metatarsal to reduce pain and promote healing. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Initial Imaging: Plain radiographs (anteroposterior, oblique, and lateral views) should be the first imaging study 2, 3

   • Early in the disease process, radiographs may appear normal
   • Advanced cases will show flattening and fragmentation of the metatarsal head

2. Advanced Imaging (if radiographs are negative but clinical suspicion remains high):

   • MRI without contrast: Most sensitive for early detection, showing hypointensity of the metatarsal head 2, 1
   • Bone scan: May demonstrate a photopenic center with a hyperactive collar in early stages 2, 1

Non-Operative Treatment Protocol

For initial management of Freiberg infraction:

1. Activity Modification:

   • Reduce or eliminate weight-bearing activities that exacerbate symptoms
   • Temporary immobilization for severe cases 4

2. Off-loading Strategies:

   • Stiff-soled shoe with metatarsal pad placed proximal to the affected metatarsal head
   • Custom orthoses with metatarsal relief 4, 1

3. Pain Management:

   • NSAIDs for pain and inflammation control
   • Ice application for acute pain episodes

4. Immobilization (for moderate to severe cases):

   • Walking boot or cast for 4-6 weeks to completely off-load the affected area 4

5. Gradual Return to Activity:

   • Progressive weight-bearing as symptoms improve
   • Continued use of supportive footwear and orthoses 4

Treatment Duration and Monitoring

• Conservative treatment should be maintained for at least 6-8 weeks
• Clinical improvement should be monitored regularly
• Follow-up radiographs may be obtained to assess healing and remodeling

When to Consider Surgical Management

Conservative treatment failure is indicated by:

• Persistent pain despite 3-6 months of appropriate non-operative management
• Progressive deformity on follow-up imaging
• Functional limitation that significantly impacts quality of life

Surgical options include:

• Dorsal closing wedge osteotomy 5, 6
• Osteochondral transplantation 1, 7
• Resection arthroplasty for advanced cases 1

Key Considerations

• Freiberg infraction most commonly affects the second metatarsal head, followed by the third 1
• The condition is more common in adolescent females but can occur in both genders at various ages 1
• Early diagnosis and treatment may prevent progression to advanced stages
• Spontaneous healing with remodeling can occur in early stages with appropriate off-loading 1
• The condition is often mistaken for a stress fracture, leading to delayed diagnosis 4

Early non-operative management is crucial as outcomes are generally good to excellent with appropriate treatment, allowing most patients to return to previous activity levels 1.