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Femoral Neck Stress Fracture Treatment & Management

  • Author: Scott D Flinn, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: May 12, 2014
 

Acute Phase

Rehabilitation Program

Physical Therapy

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

Medical Issues/Complications

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.[16]

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

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.

Consultations

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.

Other Treatment

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.

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Recovery Phase

Rehabilitation Program

Physical Therapy

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.

Medical Issues/Complications

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.

Surgical Intervention

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.

Consultations

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.

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Maintenance Phase

Rehabilitation Program

Physical Therapy

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.

Medical Issues/Complications

If the same type of pain reappears despite therapy, the patient should return to the clinician to check for a recurrent stress fracture.

Surgical Intervention

If the femoral neck was surgically fixed, consult the orthopedic specialist regarding when (if ever) the pins should be removed.

Consultations

Obtain an orthopedic consultation if the patient's recovery is not progressing adequately.

Other Treatment

The patient should continue calcium supplementation, if necessary. Monitor for recurrence of an eating disorder, if appropriate.

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Contributor Information and Disclosures
Author

Scott D Flinn, MD Medical Director, Arch Health Partners

Scott D Flinn, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

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.

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

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.

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

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

  11. 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. 1996 May. 11(5):645-53. [Medline].

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

  13. 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. 2004 Sep. 32(6):1528-34. [Medline].

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

  15. Harder AT, An YH. The mechanisms of the inhibitory effects of nonsteroidal anti-inflammatory drugs on bone healing: a concise review. J Clin Pharmacol. 2003 Aug. 43(8):807-15. [Medline].

  16. 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. 2006 Dec. 88(12):1574-9. [Medline].

  17. 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].

 
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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.
Radiographs 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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