Femoral Neck Stress Fracture Treatment & Management
- Author: Scott D Flinn, MD; Chief Editor: Sherwin SW Ho, MD more...
Tension-side FNSF should be non-weightbearing and receive immediate referral to an orthopedic surgeon. Compression-side fractures may be treated conservatively. Compression-side fractures should be referred as appropriate for expert care if not familiar with their treatment.
Follow the acute treatment principles of protection, rest, ice, compression, elevation, medication, and modalities (PRICEMM). This treatment regimen is most appropriate for compression (as opposed to tension) fractures. Patient compliance is important.
Protection – Crutches with non–weight-bearing ambulation until complete relief of pain at rest is achieved
Rest – Non-weight bearing if there is pain at rest; may do alternative exercises to maintain cardiovascular conditioning (eg, swim, upper-extremity Exercycle [Exercycle Company, Franklin, Mass])
Ice – To assist with pain reduction
Elevation – Usually difficult
Medication – Consider low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief or narcotics if the patient has severe pain. NSAIDs should be given for as short a time as possible as they may interfere with bone healing. [14, 15]
Modalities – Not much help acutely
Nondisplaced compression-side FNSFs do well with conservative treatment, ie, non-weightbearing on crutches, with a gradual progression to touchdown weightbearing, partial weight bearing, then to no crutches in 4-6 weeks depending on the clinical response. These patients do not appear to be at increased long-term risk for avascular necrosis of the femoral head or osteoarthritis.
Nondisplaced tension-side fractures are usually treated with surgical pinning. Rarely, conservative treatment such as for compression-side fractures is attempted for small, nondisplaced tension-side FNSFs. Displaced fractures are treated surgically.
Surgical intervention is dependent on the type of fracture. Compression-side fractures can be treated with conservative therapy. Nondisplaced tension-side FNSFs are usually treated with prophylactic surgical fixation. Rarely, a trial of conservative therapy in compliant patients may be attempted if the tension-side fracture is small and not displaced. Urgently refer the patient for orthopedic evaluation for surgical fixation in cases of displaced fractures.
Consult an orthopedic specialist if the patient's rehabilitation for an FNSF is not progressing adequately, if it is displaced, or for any other concerns.
Review the patient's diet; ensure adequate calcium and vitamin D intake, and supplement as needed. Consider oral contraceptives for amenorrheic women; such agents may aid in the recovery of bone mass in these women. Athletes with eating disorders may need psychologic and nutritional support.
As the patient’s pain decreases, gradually increase activity from non-weight bearing to touchdown weight bearing, then to partial weight bearing, and eventually, discontinuation of the crutches. This process usually takes 4-6 weeks. Coordinate the patient's rehabilitation with the orthopedic specialists for those individuals who have hips with surgical pinning. After the patient is able to walk 1.5 miles without pain (usually in 8-12 wk, but sometimes longer), begin a gradual return to a running program. Usually, it takes approximately 2.5 months to be able to run 3 miles pain free. If pain returns during the rehabilitation period, decrease the patient's activity until walking is pain free again.
Non–weight-bearing training can also play a role in the patient's rehabilitation. Activities such as running in water with an appropriate floatation vest can be helpful. Upper-extremity resistance exercises and aerobic training can also be used.
A very mild pain may return briefly when the patient first attempts to run. If the pain is more than a very mild intensity, the stress fracture may not have healed completely yet and needs additional rest. If the patient's pain is severe, obtain another x-ray to check for displacement. Avascular necrosis, nonunion, malunion, and eventual hip replacement may result from complications of an FNSF that is not diagnosed in time or that is rehabilitated too quickly.
If the patient has a nondisplaced tension-side fracture and the pain persists for longer than 2 weeks—despite true compliance with non-weightbearing status—consider surgical fixation if the procedure has not already been performed.
Consult an orthopedic specialist if the patient's rehabilitation for an FSNF is not progressing adequately.
Other Treatment (Injection, manipulation, etc.)
Ensure the patient has an adequate calcium and vitamin D intake. If an eating disorder is present, monitor the patient's treatment and help the patient recover proper dietary and weight-management habits.
Monitor the patient's activity to ensure that the same training errors that initially resulted in the stress fracture are not committed again. Gradual increases in mileage (≤ 10%/wk) are generally accepted as safe and effective. Likewise, the intensity of the patient's workouts should increase gradually, not dramatically.
If the same type of pain reappears despite therapy, the patient should return to the clinician to check for a recurrent stress fracture.
If the femoral neck was surgically fixed, consult the orthopedic specialist regarding when (if ever) the pins should be removed.
Obtain an orthopedic consultation if the patient's recovery is not progressing adequately.
The patient should continue calcium supplementation, if necessary. Monitor for recurrence of an eating disorder, if appropriate.
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