Femoral Neck Stress Fracture Clinical Presentation

  • Author: Scott D Flinn, MD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Feb 28, 2010
 

History

Runners and military trainees develop stress fractures as the duration, frequency, and intensity of weight-bearing activities is increased. Furthermore, changes in running surfaces, such as from a flat surface to hills, or carrying a pack may increase the risk of stress fractures.

The patient reports a gradually worsening deep, achy pain in the hip, groin, or thigh.

Usually, pain initially occurs after an activity. As the stress of training continues, pain occurs during training and becomes more intense.

Unless the form of the activity is modified, the pain gradually worsens over a few weeks to the point where the patient is unable to walk without pain.

Continued activity will probably result in completion of the stress fracture.

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Physical

Physical examination reveals the patient to have an antalgic gait.

Unlike many other stress fractures, it is not possible to palpate the femoral neck and determine the presence of the usual bony tenderness of a stress fracture. However, hip palpation may suggest another diagnosis, such as a hip flexor strain, if pain is present at the anterior inferior iliac spine and upon hip flexion. Other possible diagnoses include greater trochanteric bursitis, adductor strain, or a pubic ramus stress fracture. (See also the eMedicine articles Trochanteric Bursitis [in the Sports Medicine section], Adductor Strain [in the Physical Rehabilitation and Medicine section], and Pelvic Fractures [in the Orthopedic Surgery section].)

Pain at the extremes of passive range of motion (ROM), especially external and internal rotation, is the most sensitive sign for stress fractures.

Pain that is associated with log rolling, axially loading a supine patient (heel tap), and with single-leg standing or hopping also suggests a stress fracture. (Note: Performing a single-leg hopping test in a patient with a potential FNSF is risky and may cause completion of the stress fracture; this practice is not advised.)

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Causes

Improper training is the most obvious cause for a stress fracture. Increasing the duration, frequency, and/or intensity of training too quickly does not allow for proper bone and supporting muscle adaptation, resulting in microscopic damage to the bone, which cannot be healed quickly.

In the military population, trainees who have initially lower levels of fitness and higher body mass indexes are at an increased risk of stress fractures.[1] A history of a previous stress fracture is also a risk factor for a recurrence. In addition, coxa vara has been associated with an increased risk of FNSF.[10]

Other hypothesized risk factors for FNSF include improper footwear, leg-length discrepancies, and a change of the running surface.

Females with the female athlete triad (ie, disordered eating, menstrual dysfunction, premature osteoporosis) are also at increased risk for stress fractures. (See also the eMedicine article Female Athlete Triad.)

Young women who exercise regularly can increase the bone density of their femoral neck.

Plebes undergoing training at the US Naval Academy who had significant weight loss and smaller muscle mass were associated with a much higher incidence of stress fracture than their fitness-matched cohorts.[3]

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Contributor Information and Disclosures
Author

Scott D Flinn, MD  Officer in Charge, Surface Warfare Medicine Institute

Scott D Flinn, MD is a member of the following medical societies: American Academy of Family Physicians and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Gerard A Malanga, MD  Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Cephalon Honoraria Speaking and teaching; Endo Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

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

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

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding

References

  1. Shaffer RA, Rauh MJ, Brodine SK, Trone DW, Macera CA. Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med. Jan 2006;34(1):108-15. [Medline]. [Full Text].

  2. DeFranco MJ, Recht M, Schils J, Parker RD. Stress fractures of the femur in athletes. Clin Sports Med. Jan 2006;25(1):89-103, ix. [Medline].

  3. Armstrong DW 3rd, Rue JP, Wilckens JH, Frassica FJ. Stress fracture injury in young military men and women. Bone. Sep 2004;35(3):806-16. [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. Weistroffer JK, Muldoon MP, Duncan DD, Fletcher EH, Padgett DE. Femoral neck stress fractures: outcome analysis at minimum five-year follow-up. J Orthop Trauma. May 2003;17(5):334-7. [Medline].

  6. Lee CH, Huang GS, Chao KH, Jean JL, Wu SS. Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases. Arch Orthop Trauma Surg. Dec 2003;123(10):527-33. [Medline].

  7. [Best Evidence] Pihlajamäki HK, Ruohola JP, Kiuru MJ, Visuri TI. Displaced femoral neck fatigue fractures in military recruits. J Bone Joint Surg Am. Sep 2006;88(9):1989-97. [Medline].

  8. Egol KA, Koval KJ, Kummer F, Frankel VH. Stress fractures of the femoral neck. Clin Orthop Relat Res. Mar 1998;348:72-8. [Medline].

  9. Jones BH, Harris JM, Vinh TN, Rubin C. Exercise-induced stress fractures and stress reactions of bone: epidemiology, etiology, and classification. Exerc Sport Sci Rev. 1989;17(1):379-422. [Medline].

  10. Carpintero P, Leon F, Zafra M, et al. Stress fractures of the femoral neck and coxa vara. Arch Orthop Trauma Surg. Jul 2003;123(6):273-7. [Medline].

  11. Stovitz SD, Arendt EA. NSAIDs should not be used in treatment of stress fractures [letter]. Am Fam Physician. Oct 15 2004;70(8):1452, 1454. [Medline]. [Full Text].

  12. Beck TJ, Ruff CB, Mourtada FA, et al. Dual-energy X-ray absorptiometry derived structural geometry for stress fracture prediction in male U.S. Marine Corps recruits. J Bone Miner Res. May 1996;11(5):645-53. [Medline].

  13. Blomfeldt R, Törnkvist H, Eriksson K, et al. A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg Br. Feb 2007;89(2):160-5. [Medline].

  14. Kunesová M, Koudela K Jr, Koudela K Sr, Koudelová J. [Magnetic resonance imaging for examination of proximal femoral fractures: its contribution to clinical medicine] [Czech]. Acta Chir Orthop Traumatol Cech. Dec 2006;73(6):380-6. [Medline].

  15. Lloyd T, Petit MA, Lin HM, Beck TJ. Lifestyle factors and the development of bone mass and bone strength in young women. J Pediatr. Jun 2004;144(6):776-82. [Medline].

  16. Macaulay W, Yoon RS, Parsley B, Nellans KW, Teeny SM. Displaced femoral neck fractures: is there a standard of care?. Orthopedics. Sep 2007;30(9):748-9. [Medline].

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

  18. Pihlajamäki HK, Ruohola JP, Weckström M, Kiuru MJ, Visuri TI. Long-term outcome of undisplaced fatigue fractures of the femoral neck in young male adults. J Bone Joint Surg Br. Dec 2006;88(12):1574-9. [Medline].

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

  20. Raaymakers EL. Fractures of the femoral neck: a review and personal statement. Acta Chir Orthop Traumatol Cech. 2006;73(1):45-59. [Medline].

  21. Shimizu T, Miyamoto K, Masuda K, et al. The clinical significance of impaction at the femoral neck fracture site in the elderly. Arch Orthop Trauma Surg. Sep 2007;127(7):515-21. [Medline].

  22. Strömqvist B, Hansson LI, Ljung P, Ohlin P, Roos H. Pre-operative and postoperative scintimetry after femoral neck fracture. J Bone Joint Surg Br. Jan 1984;66(1):49-54. [Medline]. [Full Text].

  23. Yih-Shiunn L, Chien-Rae H, Wen-Yun L. Surgical treatment of undisplaced femoral neck fractures in the elderly. Int Orthop. Oct 2007;31(5):677-82. [Medline].

 
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Radiograph showing a tension-side, completed femoral neck stress fracture.
Radiograph showing sclerosis on the compression side of the femoral neck.
Radiograph are often initially negative for stress fractures, including femoral neck stress fractures. Repeating x-ray films in 2 weeks may show the changes of a stress fracture, but approximately 20% of cases do not. Bone scanning or magnetic resonance imaging may be necessary to rule out a stress fracture. In the x-ray film for this patient, no changes were seen, but a bone scan showed an obvious compression stress fracture of the right femoral neck.
 
 
 
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