Femoral Neck Stress Fracture Treatment & Management
- Author: Scott D Flinn, MD; Chief Editor: Sherwin SW Ho, MD more...
Acute Phase
Rehabilitation Program
Physical Therapy
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 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.
- Modalities – Not much help acutely
Medical Issues/Complications
If the stress fracture is on the compression side of the femoral neck and if the fracture is not displaced, patients usually do well with conservative management (non-weight bearing on crutches), with a gradual progression to touchdown weight bearing, partial weight bearing, then to no crutches in 4-6 weeks, depending upon the clinical response.
Tension-side fracture treatment is somewhat controversial, with some physicians advocating surgical pinning (even for nondisplaced fractures) and others advocating conservative treatment such as for compression-side fractures. In a compliant patient who will maintain non-weight bearing on crutches, a trial of conservative treatment with non-weight bearing on crutches is recommended for both types of fractures unless displacement is present, in which case, urgent referral for operative evaluation and fixation is indicated.
Treatment of the tension-side stress fracture is based on the completeness of the fracture (ie, unicortical vs bicortical), which, in turn is, based on a classification scheme. In general, bicortical tension-side fractures are treated surgically.
Surgical Intervention
Surgical intervention is dependent upon the type of fracture. Compression-side fractures can be treated with conservative therapy. Nondisplaced tension-side treatment is controversial, with some physicians advocating prophylactic surgical fixation and others advocating a trial of conservative therapy in compliant patients. Urgently refer the patient for orthopedic evaluation for surgical fixation in cases with displaced fractures.
Consultations
Regardless of the presence or absence of fracture displacement, tension-side stress fractures of the femoral neck should be managed in coordination with an orthopedic specialist.
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.
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's pain persists for longer than 2 weeks—despite true compliance with non–weight-bearing status on a tension-side, nondisplaced stress fracture—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.
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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