eMedicine Specialties > Sports Medicine > Hip
Femoral Neck Stress Fracture: Treatment & Medication
Updated: Feb 28, 2010
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications in patients with FNSFs.
Mineral supplements
Calcium supplementation may be necessary for patients with FNSFs. The average daily recommendations for children aged 9-18 years is 1300 mg of calcium daily. Individuals aged 19-50 years and postmenopausal women should have a daily calcium intake of 1000 mg of calcium. Middle-aged women and males 50 years and older should receive 1200 mg of calcium daily. Vitamin D supplementation may also be necessary.
Calcium carbonate (Os-Cal)
Used for the supplementation of calcium. Give the amount that is needed to supplement an individual's diet to reach the recommended daily amounts.
Adult
500 mg PO qd
Pediatric
Not established
May decrease the effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; IV administration antagonizes the effects of verapamil; large intakes of dietary fiber may decrease calcium absorption and levels
Renal calculi, hypercalcemia, hypophosphatemia, renal or cardiac disease, patients with digitalis toxicity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in digitalized patients and in the presence of respiratory failure or acidosis
Calcium citrate (Citracal)
Moderates nerve and muscle performance by regulating the action potential excitation threshold. Give the amount that is needed to supplement an individual's diet to reach the recommended daily amounts.
Adult
200 mg PO qd
Pediatric
Not established
May decrease the effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; IV administration antagonizes the effects of verapamil; large intakes of dietary fiber may decrease calcium absorption and levels
Renal calculi, hypercalcemia, hypophosphatemia, renal or cardiac disease, patients with digitalis toxicity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in digitalized patients and in the presence of respiratory failure or acidosis
Nonsteroidal anti-inflammatory drugs
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions. Many NSAIDs are currently on the market. There is no evidence to support that one agent is more efficacious than another; however, individual response may differ.
The routine use of NSAIDs for treating stress fractures has been called into question because these drugs have been shown to slow bone formation and may mask the pain that serves as a guide for the timing of advancing rehabilitation.11 Therefore, administer NSAIDs sparingly for initial pain, if at all. Furthermore, with the other complications of NSAIDs (eg, gastrointestinal [GI] bleeding) and the known difficulties with COX-2 inhibitors, caution is advised.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with initial mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. May slow bone healing, so use sparingly.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or a high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; caution patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy
Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis. May slow bone healing, so use sparingly.
Adult
500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Ketoprofen (Actron, Orudis, Oruvail)
For relief of mild to moderate pain and inflammation.
Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response. May slow bone healing, so use sparingly.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy
More on Femoral Neck Stress Fracture |
| Overview: Femoral Neck Stress Fracture |
| Differential Diagnoses & Workup: Femoral Neck Stress Fracture |
 Treatment & Medication: Femoral Neck Stress Fracture |
| Follow-up: Femoral Neck Stress Fracture |
| Multimedia: Femoral Neck Stress Fracture |
| References |
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References
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Further Reading
Keywords
stress fracture of the hip, hip pain, hip replacement, total hip replacement, femoral stress fracture, FNSFs
