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Femoral Stress Fracture

Femoral Stress Fracture typically occurs on the superior side (tension-side fractures) or the inferior side (compression side fractures) of the femoral neck. Seen most frequently in runners, dancers, and military recruits.

It is estimated that up to 5% of all stress fractures involve the femoral neck, with another 5% involving the femoral head.

Stress fractures result from accelerated bone remodeling in response to repeated stress. Although stress fractures are a relatively uncommon etiology of hip pain.

See Also: 	Pelvic Fractures
Femoral head neck blood supply
Femoral head neck blood supply

Stress Fracture Classification

Femoral Neck Stress fractures are generally classified as fatigue or insufficiency fractures:

  • Fatigue stress fractures are caused by repetitive and abnormally high forces from muscle action and/or weightbearing torques and are often found in persons with normal bone densities. This type of stress fracture at the hip is most common in athletes involved in intense training, including military personnel.
  • Insufficiency stress fractures are associated with individuals who have compromised bone densities. Since insufficiency stress fractures are associated with decreased bone mineral density, they tend to be most common in the elderly, especially postmenopausal women. Other predisposing factors for poor bone density include radiation treatments, rheumatoid arthritis due at least in part to the associated disuse and either corticosteroid or methotrexate treatment, renal failure, coxa vara, metabolic disorders, and Paget’s disease.
compression and tension side of the femoral neck
Compression and tension side of the femoral neck

Femoral Neck Stress fractures can also be classified based on symptoms and imaging appearance:

GradePainImaging
IIncidental “stress reaction” found on imaging – No fracture line.
II+Bone fatigue found on imaging – No fracture line.
III+Nondisplaced fracture line on imaging
IV+Fracture displacement ≥ 2 mm identified on imaging
V+Nonunion fracture identified on imaging

Femoral Neck Stress Fracture Symptoms

the diagnosis of a femoral neck stress fracture is often delayed for 5 to 13 weeks.

The most frequent symptom is the onset of sudden hip pain, usually associated with a recent change in training (particularly an increase in distance or intensity) or a change in training surface. The earliest and most frequent symptom is pain in the deep thigh, inguinal, or anterior groin area.

Pain can also occur in the lateral aspect or anteromedial aspect of the thigh. The pain usually occurs with weightbearing or at the extremes of hip motion and can radiate into the knee. Less severe cases may only have pain following a long run. Night pain may occur if the fracture progresses.

The physical examination is often negative, although there may be a noncapsular pattern of the hip, an empty end-feel, or pain at the extremes of hip internal or external rotation or pain with resisted hip external rotation. In addition, the auscultatory patellar-pubic percussion test may be positive.

Subtle limitation of flexion and internal rotation may also be present with or without a positive log roll test.

Femoral neck Stress Fracture
Femoral neck Stress Fracture

Differential Diagnosis

Differential diagnosis of Femoral Stress Fracture includes:

  • OA of the hip,
  • referred symptoms from the spine,
  • trochanteric bursitis,
  • septic arthritis.
See Also: Log Roll Test

Imaging

Recommended views include AP pelvis, AP and lateral of hip.

Only 10% of patients will demonstrate positive findings on plain radiographs taken within the first week of symptoms, and fewer than 55% of patients with femoral neck stress fractures will ever have radiographic evidence of the condition.

Although bone scans provide a high sensitivity in detecting stress fractures, their low specificity combined with a relatively high dose of radiation make magnetic resonance imaging (MRI) the modality of choice in detecting stress fractures.

MRI is a high sensitive and specific for diagnosis, and detects early changes.

Femoral Stress Fracture Treatment

The treatment of Femoral Stress Fracture varies according to the bone scintigraphy findings:

  1. If there is a positive scan only, or sclerosis and no fracture line on the radiographs, the intervention ranges from modified bed rest to non–weight-bearing with crutches until symptoms subside. Once pain free, weight-bearing is progressed. When significant PWB is pain free, cycling and swimming may be permitted. Weekly radiographs are obtained until the athlete is full weight-bearing without pain. Water running and water walking are progressed. If these remain pain free, running on land is commenced, with the initial run being no further than one-quarter mile.
  2. If there is an overt fracture line on the radiographs with no displacement, and provided that only the cortex is involved, an initial period of either bed rest or complete non–weightbearing is necessary. The patient is progressed to partial and then full weight-bearing on crutches as symptoms permit. Roentgenograms every 2–3 days during the first week are necessary to detect any widening of the fracture line. If healing does not occur, internal fixation with some form of hip pin is indicated.
  3. An overt fracture with radiographic evidence of opening or displacement is significant and requires surgical intervention, usually in the form of a hip screw and plate. Displaced fractures must be treated as an orthopedic emergency.

Tension-sided femoral neck stress fracture is an indication for surgical fixation with parallel screws or a sliding hip screw device. While compression side stress fractures with no displacement is an indication for non-operative treatment.

Femoral Shaft Stress Fractures

Stress fractures of the femoral shaft are diagnosed most commonly in runners, in particular female runners, with the most common location being the junction of the proximal and middle thirds of femoral shaft.

As with most stress injuries of bone, the history often reveals a recent increase in frequency, intensity, or duration of a repetitive activity.

Pain with running then progresses to pain with activities of daily living and functional limitation.

Examination is positive for an antalgic gait with normal knee and hip range of motion. Pain with palpation may be present at the anterior thigh with hopping on the affected leg reproducing the pain. The fulcrum or “hanging leg” test involves having the patient seated on an examination table with the leg hanging freely. A three-point bending force is then applied to the thigh with the edge of the table being used as a
fulcrum. Pain elicited is indicative of a Femoral Shaft Stress Fractures.

fulcrum or “hanging leg” test
Fulcrum or “hanging leg” test

As with most stress injuries plain x-rays are typically negative early in the course of the injury. Fracture callus and a radiolucent fracture line usually appear 2 to 6 weeks after symptom onset. Bone scan or MRI may be necessary for an early diagnosis.

Nonoperative treatment of femoral shaft stress fractures is usually successful.

First-line interventions include protected weight bearing with crutches for 1 to 4 weeks depending on symptom severity and radiologic grade of the injury. Activity modification with cross-training during this time period allows maintenance of aerobic fitness, skill, and strength. If the patient is pain free with day-to-day activities at 2 weeks, a rehabilitation program with low-impact exercise may be initiated.

Time to full recovery varies, but has been reported as 5 to 10 weeks from diagnosis with return to full athletic participation at 8 to 16 weeks.

Femoral shaft stress Fracture
Femoral shaft stress Fracture

References

  1. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000 Nov-Dec;8(6):344-53. doi: 10.5435/00124635-200011000-00002. PMID: 11104398.
  2. Clough TM: Femoral neck stress fracture: the importance of clinical suspicion and early review. Br J Sports Med 36:308–309, 2002.
  3. Fullerton LR Jr, Snowdy HA: Femoral neck stress fractures. Am J Sports Med 16:365–367, 1988.
  4. Jones DL, Erhard RE: Diagnosis of trochanteric bursitis versus femoral neck stress fracture. Phys Ther 77:58–67, 1997.
  5. Gurney B, Boissonnault WG, Andrews R: Differential diagnosis of a femoral neck/head stress fracture. J Orthop Sports Phys Ther 36:80–88, 2006.
  6. Pouilles JM, Bernard J, Tremollières F, et al. Femoral bone density in young male adults with stress fractures. Bone. 1989;10:105–108.
  7. Toren A, Goshen E, Katz M, et al. Bilateral femoral stress fractures in a child due to in-line (roller) skating. Acta Paediatr. 1997;86:332–333.
  8. Pegrum, J, Crisp, T, and Padhiar, N: Diagnosis and management of bone stress injuries of the lower limb in athletes. BMJ, 344:e2511, 2012.
  9. Shin, AY, and Gillingham, BL: Fatigue fractures of the femoral neck in athletes. J Am Acad Orthop Surg, 4:293, 1997.
  10. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
  11. Rockwood and Green’s Fractures in Adults 8th Edition book.
Last Reviewed
October 15, 2023
Contributed by
OrthoFixar

Orthofixar does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice.

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