Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Femoral Neck Fracture Clinical Presentation

  • Author: Gerard A Malanga, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Jan 19, 2016
 

History

Establishing a diagnosis in an athlete experiencing groin or hip pain with ambulation begins with a detailed history and physical examination. The basic history should include a temporal account of the patient's symptoms and a complete description of complaints. The clinician should ask the patient whether the symptoms are associated with participation in a specific sport or activity. A comprehensive training history should be obtained, and recent changes in activity level, equipment, intensity levels, and technique should be noted.

  • A careful menstrual history should be obtained from all female patients. Amenorrhea is often associated with decreased serum estrogen levels. Lack of protective estrogen leads to decreases in bone mass. The female athlete triad of amenorrhea, osteoporosis, and disordered eating affects many active women. Signs and symptoms of the female triad include the following:
    • Fatigue
    • Anemia
    • Depression
    • Cold intolerance
    • Lanugo
    • Eroded tooth enamel
    • Use of laxatives
  • Poor eating habits can lead to disturbances of the endocrine, cardiovascular, and gastrointestinal systems and to irreversible bone loss. The clinician should be alert to stress fractures and understand the possible signs of the female athlete triad, particularly noting unusual fractures that occur from minimal trauma.
  • Most athletes describe an insidious onset of pain over 2-3 weeks, which corresponds with a recent change in training or equipment. Typically, runners have recently increased their mileage or intensity, changed their terrain, or switched running shoes. The physician should inquire about the individual's training log and mileage.
  • Features common to all stress fractures include the following:
    • Participation in repetitive cyclic activity
    • Insidious onset of pain
    • Recent change in activity or equipment
    • Atraumatic history
    • Pain with weight bearing
    • Relief of pain with rest
    • Menstrual irregularities
    • Predisposing osteopenia
  • Patients usually report a history of gradual- or acute-onset anterior hip, groin, or knee pain that worsens with exercise. A typical feature of a stress fracture is a history of exercise-related localized pain that increases with activity and either abates with rest or persists with less forceful activity. Pain progressively worsens with continued training. The pain is reproducible with repeated activity, and it is relieved with rest.
  • The examiner should inquire whether these symptoms have occurred in the past, and, if so, whether the patient tried using ice or heat or any medications (eg, acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs]). Questions should be asked about previous participation in a physical therapy program, and the physician should attempt to understand the treatment plan used.
Next

Physical

A comprehensive physical examination of the athlete with groin or hip pain should include an in-depth evaluation of the neurologic and musculoskeletal systems. Combining the findings from the history and physical examination should increase the overall predictive value of the evaluation process. The degree and type of fracture usually dictate the severity of clinical deformity.

  • Inspection: The examination begins with observation of the patient during the history portion of the evaluation. Note any grimacing or abnormal gait patterns. Patients with displaced femoral neck fractures are usually unable to stand or ambulate. Observe the iliac crest for any difference in height, which may indicate a functional leg-length discrepancy. Alignment and length of the extremity is usually normal; however, the classic presentation of patients with displaced fractures is a shortened and externally rotated extremity. Assessing for any muscle atrophy or asymmetry is also important.
  • Palpation: Determine any tender points in the anterior groin and hip regions. The most common physical feature of stress fractures in general is local bony tenderness; however, the neck of the femur is relatively deep and bony pain or tenderness may be absent. Palpate the trochanter for any tenderness that might indicate trochanteric bursitis.
  • Range of motion: Determine the range of motion for hip flexion, extension, abduction, adduction, and internal and external rotation and for knee flexion and extension. Findings include pain and restriction at the end of passive range of motion at the hip. Perform a passive straight-leg raise, Thomas, and rectus femoris stretch test. Examine the iliotibial band by performing the Ober test.
  • In addition to range of motion of the hip, assess the spine and other lower extremity joints, because pain referral patterns may be confusing. Examine the low back both actively and passively, looking at forward flexion, side bending, and extension. Perform a straight-leg raise test and tests for the Lasegue and Bragard signs. A patient with anterior thigh and knee pain may actually have pathology at the hip joint. Reproduction of the patient's pain with hip internal rotation, external rotation, or other provocative maneuvers may further distinguish hip pathology from spine involvement.
  • Muscle strength: Manual muscle testing is important to determine whether weakness is present and whether the distribution of weakness corresponds to any nerve injuries. Additionally, evaluate the dynamic stabilizers of the pelvis, including hip flexors, extensors, and abductors. A Trendelenburg gait pattern is indicative of hip abduction weakness. Test hip flexion (L2, L3), extension (L5, S1, S2), abduction (L4, L5, S1), and adduction (L3, L4).
  • Sensory examination: Upon sensory examination, a dermatomal decrease or loss of sensation can indicate or exclude any specific nerve damage. Muscle stretch reflexes are helpful in the evaluation of patients presenting with hip pain. Abnormal reflexes can indicate nerve root abnormality. The asymmetry of reflexes is most significant; therefore, a patient's reflexes must be compared with the contralateral side.
  • Hop test: Approximately 70% of patients with stress fractures of the femur demonstrate a positive hop test result. The hop test involves the patient hopping on the affected leg to reproduce symptoms. Other maneuvers that can place a stress on the femur also may reproduce pain.
Previous
Next

Causes

Training errors are the most common risk factors for femoral neck fractures, including a sudden increase in the quantity or intensity of training and the introduction of a new activity. Other factors include low bone density, abnormal body composition, dietary deficiencies, biomechanical abnormalities, and menstrual irregularities.

  • Predisposing factors, such as anatomic variations, relative osteopenia, poor physical conditioning, systemic medical conditions that demineralize bone, or temporary inactivity, can make bone more susceptible to stress fractures. As reported by Monteleone, studies have indicated that women have an increased incidence of stress fractures, which may be the result of anatomic variations.[15] Women tend to direct axial force during weight bearing along different axes of long bones compared with men. Women also have 25% less muscle mass per body weight than men. This may concentrate, rather than dissipate, the stabilizing forces through the bony anatomy.
  • Markey reported that Hersman et al documented women have a higher incidence of stress fractures.[12] This higher incidence is partly a result of mechanical differences and anatomic variations between men and women. Differences in women include various stride lengths, number of strides per distance, a wider pelvis, coxa vara, and genu valgum.
  • Exercise-induced endocrine abnormalities are well known to result in amenorrhea or nutritional deficiencies, which can lead to bone demineralization and can place these patients at risk for various overuse injuries. Stress fractures, especially in trabecular bone, have shown a decrease in bone mineral content. This decrease can be reproduced by a decrease in circulating estrogen, which is observed in amenorrheic female athletes. Lack of protective estrogen leads to a decrease in bone mass. The female athlete triad of amenorrhea, osteoporosis, and disordered eating affects many active women. Irreversible bone loss places the patient at a higher risk for fractures.
  • Most people are not competitive athletes and may not be at a level of optimum fitness. Individuals often force themselves to participate at a level for which they are not physically fit. Flexibility, muscle strength, and neuromuscular coordination contribute to injuries when individuals are not properly trained.
Previous
 
 
Contributor Information and Disclosures
Author

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Neil N Jasey, Jr, MD Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey

Disclosure: Nothing to disclose.

Jennifer Solomon, MD Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey

Jennifer Solomon, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

References
  1. Schnackenburg KE, Macdonald HM, Ferber R, Wiley JP, Boyd SK. Bone quality and muscle strength in female athletes with lower limb stress fractures. Med Sci Sports Exerc. 2011 Nov. 43(11):2110-9. [Medline].

  2. Singh PJ, O'Donnell JM. The outcome of hip arthroscopy in Australian football league players: a review of 27 hips. Arthroscopy. 2010 Jun. 26(6):743-9. [Medline].

  3. Konetsky M, Miller J, Tripp C. Femoral neck stress fracture. J Orthop Sports Phys Ther. 2013 Apr. 43(4):275. [Medline].

  4. Plancher KD, Donshik JD. Femoral neck and ipsilateral neck and shaft fractures in the young adult. Orthop Clin North Am. 1997 Jul. 28(3):447-59. [Medline].

  5. Brukner P. Sports medicine. The tired athlete. Aust Fam Physician. 1996 Aug. 25(8):1283-8. [Medline].

  6. Lakstein D, Hendel D, Haimovich Y, Feldbrin Z. Changes in the pattern of fractures of the hip in patients 60 years of age and older between 2001 and 2010: A radiological review. Bone Joint J. 2013 Sep. 95-B(9):1250-4. [Medline].

  7. Koval KJ, Zuckerman JD. Hip fractures: I. Overview and evaluation and treatment of femoral-neck fractures. J Am Acad Orthop Surg. 1994 May. 2(3):141-149. [Medline].

  8. Joshi N, Pidemunt G, Carrera L, Navarro-Quilis A. Stress fracture of the femoral neck as a complication of total knee arthroplasty. J Arthroplasty. 2005 Apr. 20(3):392-5. [Medline].

  9. Volpin G, Hoerer D, Groisman G, Zaltzman S, Stein H. Stress fractures of the femoral neck following strenuous activity. J Orthop Trauma. 1990. 4(4):394-8. [Medline].

  10. Zahger D, Abramovitz A, Zelikovsky L, Israel O, Israel P. Stress fractures in female soldiers: an epidemiological investigation of an outbreak. Mil Med. 1988 Sep. 153(9):448-50. [Medline].

  11. Maitra RS, Johnson DL. Stress fractures. Clinical history and physical examination. Clin Sports Med. 1997 Apr. 16(2):259-74. [Medline].

  12. Markey KL. Stress fractures. Clin Sports Med. 1987 Apr. 6(2):405-25. [Medline].

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

  14. Fullerton LR Jr, Snowdy HA. Femoral neck stress fractures. Am J Sports Med. 1988 Jul-Aug. 16(4):365-77. [Medline].

  15. Monteleone GP Jr. Stress fractures in the athlete. Orthop Clin North Am. 1995 Jul. 26(3):423-32. [Medline].

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

  17. Holder LE, Schwarz C, Wernicke PG, Michael RH. Radionuclide bone imaging in the early detection of fractures of the proximal femur (hip): multifactorial analysis. Radiology. 1990 Feb. 174(2):509-15. [Medline]. [Full Text].

  18. Quinn SF, McCarthy JL. Prospective evaluation of patients with suspected hip fracture and indeterminate radiographs: use of T1-weighted MR images. Radiology. 1993 May. 187(2):469-71. [Medline]. [Full Text].

  19. Blomfeldt R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J. Internal fixation versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients with severe cognitive impairment. J Bone Joint Surg Br. 2005 Apr. 87(4):523-9. [Medline].

  20. Stappaerts KH. Early fixation failure in displaced femoral neck fractures. Arch Orthop Trauma Surg. 1985. 104(5):314-8. [Medline].

  21. Scheck M. The significance of posterior comminution in femoral neck fractures. Clin Orthop Relat Res. 1980 Oct. 152:138-42. [Medline].

  22. Heetveld MJ, Raaymakers EL, van Eck-Smit BL, van Walsum AD, Luitse JS. Internal fixation for displaced fractures of the femoral neck. Does bone density affect clinical outcome?. J Bone Joint Surg Br. 2005 Mar. 87(3):367-73. [Medline].

  23. Moroni A, Hoque M, Waddell JP, Russell TA, Wippermann B, Digiovanni G. Surgical treatment and management of hip fracture patients. Arch Orthop Trauma Surg. 2011 Dec 6. [Medline].

  24. Wang F, Zhang H, Zhang Z, Ma C, Feng X. Comparison of bipolar hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis. BMC Musculoskelet Disord. 2015 Aug 28. 16:229. [Medline].

  25. Nattiv A, Kennedy G, Barrack MT, Abdelkerim A, Goolsby MA, Arends JC, et al. Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: a 5-year prospective study in collegiate track and field athletes. Am J Sports Med. 2013 Aug. 41(8):1930-41. [Medline].

  26. Arnold WD. The effect of early weight-bearing on the stability of femoral neck fractures treated with Knowles pins. J Bone Joint Surg Am. 1984 Jul. 66(6):847-52. [Medline]. [Full Text].

  27. Askin SR, Bryan RS. Femoral neck fractures in young adults. Clin Orthop Relat Res. 1976 Jan-Feb. 114:259-64. [Medline].

  28. Barnes R, Brown JT, Garden RS, Nicoll EA. Subcapital fractures of the femur. A prospective review. J Bone Joint Surg Br. 1976 Feb. 58(1):2-24. [Medline]. [Full Text].

  29. Bennell KL, Malcolm SA, Thomas SA, et al. Risk factors for stress fractures in track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996 Nov-Dec. 24(6):810-8. [Medline].

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

  31. Blomfeldt R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J. Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surg Am. 2005 Aug. 87(8):1680-8. [Medline].

  32. Bray TJ, Smith-Hoefer E, Hooper A, Timmerman L. The displaced femoral neck fracture. Internal fixation versus bipolar endoprosthesis. Results of a prospective, randomized comparison. Clin Orthop Relat Res. 1988 May. 230:127-40. [Medline].

  33. Delamarter R, Moreland JR. Treatment of acute femoral neck fractures with total hip arthroplasty. Clin Orthop Relat Res. 1987 May. 218:68-74. [Medline].

  34. Egol KA, Dolan R, Koval KJ. Functional outcome of surgery for fractures of the ankle. A prospective, randomised comparison of management in a cast or a functional brace. J Bone Joint Surg Br. 2000 Mar. 82(2):246-9. [Medline]. [Full Text].

  35. Fairclough J, Colhoun E, Johnston D, Williams LA. Bone scanning for suspected hip fractures. A prospective study in elderly patients. J Bone Joint Surg Br. 1987 Mar. 69(2):251-3. [Medline]. [Full Text].

  36. Figved W, Opland V, Frihagen F, et al. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures. Clin Orthop Relat Res. 2009 Jan 7. epub ahead of print. [Medline].

  37. Garden RS. The significance of good reduction in medial fractures of the femoral neck. Proc R Soc Med. 1970 Nov. 63(11 pt 1):1122. [Medline]. [Full Text].

  38. Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004 Aug. 86-A(8):1711-6. [Medline].

  39. Karanicolas PJ, Bhandari M, Walter SD, Heels-Ansdell D, Guyatt GH. Radiographs of hip fractures were digitally altered to mask surgeons to the type of implant without compromising the reliability of quality ratings or making the rating process more difficult. J Clin Epidemiol. 2009 Feb. 62(2):214-223.e1. [Medline].

  40. Koval KJ, Skovron ML, Aharonoff GB, Zuckerman JD. Predictors of functional recovery after hip fracture in the elderly. Clin Orthop Relat Res. 1998 Mar. 348:22-8. [Medline].

  41. Magu NK, Rohilla R, Singh R, Tater R. Modified Pauwels' intertrochanteric osteotomy in neglected femoral neck fracture. Clin Orthop Relat Res. 2009 Jan 14. epub ahead of print. [Medline].

Previous
Next
 
Posterior view of the extraosseous blood supply to the femoral head.
Anterior view of the extraosseous blood supply to the femoral head.
Garden fracture classification.
Classification of femoral neck stress fractures.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.