Femoral Neck Stress and Insufficiency Fractures Clinical Presentation

Updated: Mar 18, 2020
  • Author: Michael S Wildstein, MD; Chief Editor: William L Jaffe, MD  more...
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Presentation

History and Physical Examination

Although femoral neck stress fractures are relatively uncommon in the general population, they must be part of any thorough physician's differential diagnosis for an athlete presenting with anterior hip or groin pain.

A history of insidious hip or groin pain that is directly related to an increase in the level or duration of athletic activity and that is relieved by rest is typical. Early diagnosis is often difficult because of the lack of an identifiable traumatic event, which tends to dissuade primary care physicians from obtaining radiographs. Even the astute physician ordering hip films upon first presentation may overlook this diagnosis because fracture callus is not evident early in the process.

A bone scan may be helpful in cases where suspicion is high but radiographic findings are equivocal. (See Workup.) The higher degree of sensitivity of bone scanning is useful in detecting stress fractures and other forms of periosteal injury without complete fracture.

In patients presenting with hip pain and negative findings during the initial workup, obtaining plain radiographs of the ipsilateral knee also should be considered. Referred pain along the course of the anterior branch of the obturator nerve may manifest as ipsilateral hip pain and should be in the clinician's differential diagnosis, especially in younger patients.

Magnetic resonance imaging (MRI), though costly, offers increased specificity in the detection of stress fractures. The importance of early detection cannot be underestimated, because the interval between the onset of symptoms and the diagnosis often dictates whether an injury can be treated with rest and protected weightbearing or if surgical intervention is required to reduce a displaced neck fracture.

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Case Study

A 29-year-old man had spent 6 months training for a marathon by running approximately 45 miles per week. He mentioned to one of his fellow runners that he had recently noticed a mild ache in his right groin. On the advice of his friend, the man took a few days off from running, and the pain resolved without further treatment.

While running in the marathon the following week, the patient developed the same ache, which not only persisted but also increased so greatly that he had to cease running at mile 14. He was driven home by a friend; upon arrival at his house, he was unable to bear weight on the right leg. At his friend's insistence, the patient traveled to an emergency department (ED), where he was seen by a physician. No films were obtained at that time, because the patient had full, painless range of motion (ROM); he was instructed to take ibuprofen and was sent home without a walking aid.

The following day, the patient went to his primary care physician and obtained a referral to a physiotherapist. After 3 weeks of therapy, he was still unable to comfortably bear weight. He returned to the ED one night the following week because his pain had persisted. The patient was told to ice the groin and was given a prescription for a cyclooxygenase-2 (COX-2) inhibitor, but he did not receive a radiograph.

The patient continued his physiotherapy for an additional 3 weeks without improvement of his symptoms, at which time his primary care physician referred him to a local orthopedic surgeon.

Upon physical examination, the patient had approximately 1.5 cm of shortening on the affected side, with severely limited ROM at the hip. A radiograph confirmed a basicervical fracture of the femoral neck, with a neck-shaft angle of 90°. MRI suggested the development of a fibrous nonunion.

The patient was taken to the operating room for open reduction and internal fixation (ORIF). A subtrochanteric osteotomy for correction of the varus deformity of the femoral neck also was contemplated, but gentle traction restored enough neck-shaft angle to permit placement of a dynamic hip screw (DHS).

At 6 months postoperatively, the fracture was thought to be sufficiently healed to allow unprotected weightbearing. At 8 months postoperatively, the patient had resumed low-impact activities, such as cycling and swimming. After more than 3 years, he had resumed recreational running without difficulty.

This case is classic in its presentation. A young male distance athlete with insidious onset of hip pain, which was likely a stress fracture of the femoral neck, went undiagnosed despite several visits to the doctor. Only after obtaining appropriate imaging studies was the truly serious nature of the patient's symptoms revealed.

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