eMedicine Specialties > Orthopedic Surgery > Hip

Femoral Neck Stress and Insufficiency Fractures: Workup

Author: Michael S Wildstein, MD, Associate Professor of Orthopaedic Surgery, Charleston Veterans Affairs Medical Center; Attending Physician, Wildstein Spine Center, PA
Coauthor(s): H Del Schutte, Jr, MD, Associate Professor of Orthopedic Surgery, Department of Orthopedic Surgery, Medical University of South Carolina
Contributor Information and Disclosures

Updated: Mar 4, 2009

Workup

Laboratory Studies

  • No particular laboratory studies aid in the diagnosis of this disorder; however, a prudent part of the preoperative workup is the ordering of standard laboratory tests (eg, blood chemistries, hemoglobin and hematocrit values, and coagulation profile). When an insufficiency fracture is suspected, the medical workup should include a search for metabolic abnormalities, including abnormal calcium, phosphate, and alkaline phosphatase values.
  • If septic arthritis of the hip is suspected, a C-reactive protein level, erythrocyte sedimentation rate, and WBC count with differential should help rule out an infectious process.

Imaging Studies

  • Plain radiography remains the initial imaging examination in the evaluation of suspected hip disease. A standard hip radiographic series includes an AP view of the pelvis and coned-down AP and frog-lateral views of the affected hip.
    • The AP view of the pelvis allows evaluation of the contralateral hip for concomitant disease and can be used to exclude osseous or articular abnormalities of the pelvis (eg, sacroiliitis, sacral stress fractures, pubic ring fractures) that could present clinically as hip pain. The AP views of the pelvis and hip are obtained with the feet internally rotated.
    • The frog-lateral view of a hip is obtained with the radiographic beam oriented in the AP direction, with the hip abducted. A groin lateral view of the hip, instead of the frog-lateral view, can be used in cases of an acute femoral neck fracture or displaced fracture, because the affected hip remains in a neutral position. In this examination, the opposite leg is abducted and elevated and the radiographic beam is oriented parallel to the table, with 20° cephalad angulation.
  • In the case of a compression-type fracture, the inferior aspect of the femoral neck demonstrates cortical thickening with a hazy, radiolucent center. This radiographic picture may be easily confused with osteoid osteoma if an adequate history is not obtained from the patient. Transverse-type fractures appear much differently on radiography, the first sign being a faint line of sclerosis across the femoral neck. If left untreated, these transverse fractures may easily progress to complete neck fractures, with significant displacement and varus angulation (see Images 1-4).
Anteroposterior and lateral images of a 54-year-o...

Anteroposterior and lateral images of a 54-year-old woman with a 2-month history of right groin pain with ambulation. Note sclerosis of the right femoral neck running perpendicular to trabeculae.

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Anteroposterior and lateral images of a 54-year-o...

Anteroposterior and lateral images of a 54-year-old woman with a 2-month history of right groin pain with ambulation. Note sclerosis of the right femoral neck running perpendicular to trabeculae.


Anteroposterior and lateral images of a 54-year-o...

Anteroposterior and lateral images of a 54-year-old woman with a 2-month history of right groin pain with ambulation. Note sclerosis of the right femoral neck running perpendicular to trabeculae.

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Anteroposterior and lateral images of a 54-year-o...

Anteroposterior and lateral images of a 54-year-old woman with a 2-month history of right groin pain with ambulation. Note sclerosis of the right femoral neck running perpendicular to trabeculae.


Anteroposterior and lateral images of a 54-year-o...

Anteroposterior and lateral images of a 54-year-old woman with a 2-month history of right groin pain with ambulation. Note sclerosis of the right femoral neck running perpendicular to trabeculae.

[ CLOSE WINDOW ]
Anteroposterior and lateral images of a 54-year-o...

Anteroposterior and lateral images of a 54-year-old woman with a 2-month history of right groin pain with ambulation. Note sclerosis of the right femoral neck running perpendicular to trabeculae.


Anteroposterior and lateral images of a 54-year-o...

Anteroposterior and lateral images of a 54-year-old woman with a 2-month history of right groin pain with ambulation. Note sclerosis of the right femoral neck running perpendicular to trabeculae.

[ CLOSE WINDOW ]
Anteroposterior and lateral images of a 54-year-o...

Anteroposterior and lateral images of a 54-year-old woman with a 2-month history of right groin pain with ambulation. Note sclerosis of the right femoral neck running perpendicular to trabeculae.

  • Because of its sensitivity in detecting periosteal injury, bone scanning has been very helpful in the absence of conventional radiographic findings.16 In the presence of stress fractures, bone scanning demonstrates focal increased uptake of the radiotracer, at the fracture site. This represents an area of increased bone turnover. One drawback to this modality, however, is that findings on scintography are often negative during the first 24 hours after stress fracture. The positive predictive value of radionuclide imaging in diagnosing femoral neck stress pathology approaches 68%.
  • Having similar sensitivity and the added advantage of greater specificity for stress fractures, MRI has become the new modality of choice for detecting stress pathology.17,18,19 In several studies, both the sensitivity and specificity of MRI in detecting femoral neck stress fractures was 100%. However, with this increased specificity comes increased price for the testing modality. In addition to being less invasive than bone scanning (no radiotracer needs to be injected), MRI provides much more information about the surrounding soft tissues. MRI has been shown to be effective in differentiating stress fracture from malignancy or infection.
  • A diagnostic MRI of a femoral neck stress fracture depicts decreased signal intensity on T1-weighted images and increased signal intensity on T2, as well as short TI inversion recovery (STIR) images with or without a low signal fracture line.

More on Femoral Neck Stress and Insufficiency Fractures

Overview: Femoral Neck Stress and Insufficiency Fractures
Workup: Femoral Neck Stress and Insufficiency Fractures
Treatment: Femoral Neck Stress and Insufficiency Fractures
Follow-up: Femoral Neck Stress and Insufficiency Fractures
Multimedia: Femoral Neck Stress and Insufficiency Fractures
References
Further Reading
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References

  1. Ernst J. Stress Fracture of the Neck of the Femur. J Trauma. Jan 1964;53:71-83. [Medline].

  2. The classic: treatment of fractures of the neck of the femur by internal fixation. Clin Orthop Relat Res. Sep-Oct 1967;54:3-11. [Medline].

  3. De Paulis F, Cacchio A, Michelini O, et al. Sports injuries in the pelvis and hip: diagnostic imaging. Eur J Radiol. May 1998;27(Suppl 1):S49-59. [Medline].

  4. Shin AY, Gillingham BL. Fatigue fractures of the femoral neck in athletes. J Am Acad Orthop Surg. Nov 1997;5(6):293-302. [Medline].

  5. Waters PM, Millis MB. Hip and pelvic injuries in the young athlete. Clin Sports Med. Jul 1988;7(3):513-26. [Medline].

  6. Zeni AI, Street CC, Dempsey RL, et al. Stress injury to the bone among women athletes. Phys Med Rehabil Clin N Am. Nov 2000;11(4):929-47. [Medline].

  7. Johansson C, Ekenman I, Tornkvist H, et al. Stress fractures of the femoral neck in athletes. The consequence of a delay in diagnosis. Am J Sports Med. Sep-Oct 1990;18(5):524-8. [Medline].

  8. Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am. Oct 2008;90(10):2254-66. [Medline].

  9. Stoneham MD, Morgan NV. Stress fractures of the hip in Royal Marine recruits under training: a retrospective analysis. Br J Sports Med. Sep 1991;25(3):145-8. [Medline].

  10. Volpin G, Hoerer D, Groisman G, et al. Stress fractures of the femoral neck following strenuous activity. J Orthop Trauma. 1990;4(4):394-8. [Medline].

  11. Blickenstaff LD, Morris JM. Fatigue fracture of the femoral neck. J Bone Joint Surg Am. Sep 1966;48(6):1031-47. [Medline].

  12. Lehman RA, Shah SA. Tension-sided femoral neck stress fracture in a skeletally immature patient. A case report. J Bone Joint Surg Am. Jun 2004;86-A(6):1292-5. [Medline].

  13. Niva MH, Kiuru MJ, Haataja R, et al. Fatigue injuries of the femur. J Bone Joint Surg Br. Oct 2005;87(10):1385-90. [Medline].

  14. Muldoon MP, Padgett DE, Sweet DE, et al. Femoral neck stress fractures and metabolic bone disease. J Orthop Trauma. Mar-Apr 2001;15(3):181-5. [Medline].

  15. Devas MB. Stress fractures of the femoral neck. J Bone Joint Surg Br. Nov 1965;47(4):728-38. [Medline]. [Full Text].

  16. Qian JG, Song YW, Tang X, Zhang S. Examination of femoral-neck structure using finite element model and bone mineral density using dual-energy X-ray absorptiometry. Clin Biomech (Bristol, Avon). Nov 1 2008;[Medline].

  17. Evans PD, Wilson C, Lyons K. Comparison of MRI with bone scanning for suspected hip fracture in elderly patients. J Bone Joint Surg Br. Jan 1994;76(1):158-9. [Medline]. [Full Text].

  18. Provencher MT, Baldwin AJ, Gorman JD, et al. Atypical tensile-sided femoral neck stress fractures: the value of magnetic resonance imaging. Am J Sports Med. Sep 2004;32(6):1528-34. [Medline].

  19. Shin AY, Morin WD, Gorman JD, et al. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. Mar-Apr 1996;24(2):168-76. [Medline].

  20. Bonnaire F, Götschin U, Kuner EH. [Early and late results of 200 DHS osteosyntheses in the reconstruction of pertrochanteric femoral fractures]. Unfallchirurg. May 1992;95(5):246-53. [Medline].

  21. Roetman B, Scholz N, Muhr G, Möllenhoff G. [Augmentive plate fixation in femoral non-unions after intramedullary nailing. Strategy after unsuccessful intramedullary nailing of the femur]. Z Orthop Unfall. Sep-Oct 2008;146(5):586-90. [Medline].

  22. Sanders DW, MacLeod M, Charyk-Stewart T, Lydestad J, Domonkos A, Tieszer C. Functional outcome and persistent disability after isolated fracture of the femur. Can J Surg. Oct 2008;51(5):366-70. [Medline].

  23. Gjertsen JE, Vinje T, Lie SA, Engesaeter LB, Havelin LI, Furnes O, et al. Patient satisfaction, pain, and quality of life 4 months after displaced femoral neck fractures: a comparison of 663 fractures treated with internal fixation and 906 with bipolar hemiarthroplasty reported to the Norwegian Hip Fracture Register. Acta Orthop. Oct 2008;79(5):594-601. [Medline].

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Keywords

femoral neck stress, femoral neck fracture, femoral neck stress fracture, femur injuries, hip fracture, fatigue fracture, insufficiency fracture, pseudofracture, exhaustion fracture, Deutschlãnder's fracture, Deutschlãnder fracture, Deutschlander's fracture, Deutschlander fracture, spontaneous fracture, march fracture, hip pain

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Contributor Information and Disclosures

Author

Michael S Wildstein, MD, Associate Professor of Orthopaedic Surgery, Charleston Veterans Affairs Medical Center; Attending Physician, Wildstein Spine Center, PA
Michael S Wildstein, MD is a member of the following medical societies: American Medical Association, South Carolina Medical Association, and Southern Orthopaedic Association
Disclosure: Medtronic Honoraria Speaking and teaching; Stryker spine Honoraria Speaking and teaching

Coauthor(s)

H Del Schutte, Jr, MD, Associate Professor of Orthopedic Surgery, Department of Orthopedic Surgery, Medical University of South Carolina
H Del Schutte, Jr, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, American Medical Association, American Orthopaedic Association, California Medical Association, Orthopaedic Research Society, South Carolina Medical Association, Southern Medical Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

Medical Editor

Steven I Rabin, MD, Clinical Associate Professor, Loyola University Medical Center; Chair, Department of Orthopedic Surgery, Dreyer Medical Clinic
Steven I Rabin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Fracture Association, AO Foundation, and Orthopaedic Trauma Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

B Sonny Bal, MD, Associate Professor, Department of Orthopedic Surgery, University of Missouri School of Medicine
B Sonny Bal, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

William L Jaffe, MD, Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases
William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, Eastern Orthopaedic Association, and New York Academy of Medicine
Disclosure: Stryker Orthopaedics Consulting fee Speaking and teaching

 
 
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