Femoral Neck Stress Fracture 

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

Background

Stress fractures are a common problem in various populations, including runners and military trainees.[1, 2, 3] These fractures can occur with as little as 2-3 weeks of training, be very mild, and cause only minimal changes to the bone, which eventually heals, or they may progress to a complete fracture that requires surgical fixation. Although rare, poor outcomes may occur in the form of nonunions or avascular necrosis. Certain stress fractures have a higher risk of poor outcome, including anterior tibial and femoral neck stress fractures (FNSFs).

(See also the eMedicine articles Femoral Head Avascular Necrosis [in the Sports Medicine section], Avascular Necrosis, Femoral Head and Stress Fracture [in the Radiology section], and Stress Fracture [in the Physical Medicine and Rehabilitation section], as well as Risk Factors for Bone tress Injuries: A Follow-up Study of 102,515 Person-Years and Total Hip Arthroplasty in the Older Population on Medscape.)

FNSFs (see image below) are some of the most difficult injuries to diagnose. The pain associated with such an injury may be poorly localized in the hip and may be referred to the thigh or back. Physical examination findings are not very specific for this injury, and diagnostic radiographs in the form of x-ray films, bone scans, and/or magnetic resonance images (MRIs) are often necessary.[4] Failure to diagnose FSNFs may lead to catastrophic consequences, including avascular necrosis of the femoral head and the need for a hip replacement in otherwise healthy young individuals.[5, 6, 7] A high index of suspicion in the appropriate risk populations is the key to diagnosing and treating FNSFs.

Radiograph showing a tension-side, completed femorRadiograph showing a tension-side, completed femoral neck stress fracture.

(See also the eMedicine article Femoral Neck Stress and Insufficiency Fractures.)

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center; Breaks, Fractures, and Dislocations Center; and Sports Injury Center. Also, see eMedicine's patient education articles Broken Leg and Total Hip Replacement.

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Epidemiology

Frequency

United States

Stress fractures may develop in up to 15% of runners and military trainees.[3] Of those patients who develop stress fractures, about 5-10% of the fractures are in the femoral neck.[8] Stress fractures on the compression side (the inferior aspect) of the femoral neck are more common than stress fractures on the tension side (the superior aspect).

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Functional Anatomy

The femoral neck lies between the femoral head and femoral shaft, demarcated by the greater and lesser trochanters. Weight-bearing forces from the trunk cause a compressive force on the inferior aspect of the femoral neck, whereas the superior aspect is subject to tensile forces.[6, 9] The blood supply to the femoral head runs through the femoral neck; thus, an FNSF may disrupt the blood supply to the femoral head and cause avascular necrosis of the femoral head.[6]

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Sport-Specific Biomechanics

The load of the runner's body weight is transmitted down the lower extremities through the bones and may exceed 3-5 times the body weight in the femoral neck during running. Muscles help to absorb forces and distribute load, especially the gluteus medius. The weight of the trunk and upper extremities applies compressive forces to the inferior aspect of the femoral neck. Conversely, tensile forces act upon the superior aspect of the femoral neck. These forces become important in the prognosis and management of the stress fracture. A sudden reduction in weight and lower muscle mass combined with daily training was associated with an increased risk of FNSF in US Naval Academy plebes.[3]

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Proceed to Clinical Presentation
 
 
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

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  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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