Femoral Neck Stress Fracture Workup

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

Laboratory Studies

Consider laboratory studies with a CBC count and erythrocyte sedimentation rate (ESR) if infection, inflammatory arthropathy, or a tumor is suspected.

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Imaging Studies

X-ray films (see images below)

Radiograph showing a tension-side, completed femorRadiograph showing a tension-side, completed femoral neck stress fracture. Radiograph showing sclerosis on the compression siRadiograph showing sclerosis on the compression side of the femoral neck.

Obtain anteroposterior and frog-leg views.

Obtain appropriate radiographs if femoral shaft or pubic ramus fractures are suspected. (See also the eMedicine article Femur Injuries and Fractures.)

If the initial radiographs are negative (and they often are), and the suspicion for FNSF is high based on the patient history and physical examination, obtain a bone scan or MRI.[4] Instruct the patient to remain non-weight bearing on crutches until the study is obtained.

If the patient's symptoms are mild, or bone scanning or MRI is unavailable, the patient should be on crutches, non-weight bearing or touchdown weight bearing, until the bone scan/MRI is obtained or repeat films in 2 weeks are negative.

See image below of a bone scan depicting FNSF.

Radiograph are often initially negative for stressRadiograph 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.

MRI

MRI yields more diagnostic information than bone scanning and is especially more useful in difficult cases.[4]

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Other Tests

Other tests, such as hip joint aspiration for a septic joint, are only indicated if the clinician is considering alternative diagnoses.

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

  3. Armstrong DW 3rd, Rue JP, Wilckens JH, Frassica FJ. Stress fracture injury in young military men and women. Bone. Sep 2004;35(3):806-16. [Medline].

  4. Shin AY, Gillingham BL. Fatigue fractures of the femoral neck in athletes. J Am Acad Orthop Surg. Nov 1997;5(6):293-302. [Medline].

  5. Weistroffer JK, Muldoon MP, Duncan DD, Fletcher EH, Padgett DE. Femoral neck stress fractures: outcome analysis at minimum five-year follow-up. J Orthop Trauma. May 2003;17(5):334-7. [Medline].

  6. Lee CH, Huang GS, Chao KH, Jean JL, Wu SS. Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases. Arch Orthop Trauma Surg. Dec 2003;123(10):527-33. [Medline].

  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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