Updated: 7/21/2018

Femoral Neck Stress Fractures

Topic
Review Topic
0
0
Questions
5
0
0
Evidence
7
0
0
https://upload.orthobullets.com/topic/3110/images/ms insertions of femur.jpg
https://upload.orthobullets.com/topic/3110/images/blood supply to fn.jpg
https://upload.orthobullets.com/topic/3110/images/biomechanics of femur.jpg
https://upload.orthobullets.com/topic/3110/images/xr compression side.jpg
https://upload.orthobullets.com/topic/3110/images/mri fn stress compression side .jpg
Introduction
  • Fracture of the femoral neck secondary to repetitive loading of bone 
    • two types
      • compression side  (inferior-medial neck)
      • tension side (superior-lateral neck)
  • Epidemiology
    • common in runners
  • Mechanism
    • repetitive loading of femoral neck
  • Pathophysiology
    • repetitive loading causes microscopic fractures in the femoral neck
      • crack "initiation"
    • continued repetitive loading does not allow for healing response and stress fracture occurs
      • crack "propagation"
  • Associated conditions
    • "female athlete triad
      • amenorrhea, eating disorder, and osteoporosis
      • must be considered in any female athlete with stress fracture
  • Prognosis
    • dependent upon patient compliance
Anatomy
  • Muscle insertions around femoral neck 
    • iliopsoas 
    • quadratus femoris 
    • gluteus medius 
    • piriformis 
  • Blood supply to femoral neck 
    • provided by two branches of the femoral artery including 
      • medial femoral circumflex artery 
      • lateral femoral circumflex artery
  • Biomechanics of femoral neck 
    • compression side 
      • inferior medial neck with weight bearing
    • tension side
      • superior lateral neck with weight bearing
Presentation
  • History
    • history of overuse or increase in normal training regimen
  • Symptoms
    • insidious onset of pain
      • improves with cessation of activity
      • high impact activities increase pain
    • anterior thigh or groin pain with weight bearing
  • Physical exam
    • usually benign exam
    • may have tenderness directly over femoral neck region with deep palpation
Imaging
  • Radiographs
    • recommended views
      • AP pelvis, AP and lateral of hip
    • findings
      • usually negative
      • later findings include linear lucency and cortical changes
  • MRI  
    • sensitive and specific for diagnosis 
    • detects early changes 
    • modality of choice for stress fractures when radiographs are normal
  • Bone scan
    • has good sensitivity but very poor specificity (therefore MRI is better) 
Treatment
  • Nonoperative
    • non-weight bearing, crutches and activity restriction
      • indications
        •  compression side stress fractures with fatigue line <50% femoral neck width  
  • Operative
    • ORIF with percutaneous screw fixation
      • indications
        • tension side stress fractures 
        • compression side stress fractures with fatigue line >50% femoral neck width
        • progression of compression side stress fractures
      • technique
        • use three 6.5mm or 7.0mm cannulated screws
        • postoperative weightbearing as tolerated
Complications
  • Fracture progression/completion
    • if fracture is unrecognized and the athlete continues to train
    • fracture completion is associated with severe, disabling complications
    • precludes return to prior activity level (elite athletes will not be able to return to prior level following displaced fracture)
  • Varus settling
  • AVN
  • Nonunion
  • Refracture
 

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Questions (5)
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(OBQ13.39) A 22 year-old college cross-country runner developed hip and groin pain that initially started while running, but is now painful when walking across campus. Radiographs show no evidence of a stress fracture, an alpha angle of 45 degrees, and a lateral center edge angle of 30 degrees. An MRI shows focal, intense marrow edema in the superior-lateral femoral neck. What is the most appropriate treatment? Review Topic

QID: 4674
1

Operative treatment with percutaneous screw placement

60%

(3351/5598)

2

Hip arthroscopy with cam resection

9%

(489/5598)

3

Hip arthroscopy to treat both cam and pincer impingment

6%

(319/5598)

4

Non-operative treatment with NSAIDs and reduction in mileage

8%

(466/5598)

5

Non-operative treatment with partial weight-bearing

17%

(953/5598)

ML 4

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ11.184) A 24-year-old female marathon runner experiences gradual onset of right groin pain. Initially it was only painful during running, but now it is painful with walking. She has no mechanical symptoms and denies back or lower leg symptoms. On exam, she has pain when attempting a straight leg raise and with passive internal rotation of the hip. Pelvis and hip radiographs demonstrate normal acetabular version and normal femoral head-neck offset. What is the next most appropriate step in her care? Review Topic

QID: 3607
1

Intra-articular hip corticosteroid injection

3%

(83/3018)

2

Tapered oral corticosteroid dosing regimen for one week

2%

(50/3018)

3

EMG and nerve conduction studies

0%

(9/3018)

4

MR imaging of the hip

92%

(2779/3018)

5

CT abdomen and pelvis to evaluate for sports hernia

3%

(88/3018)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ04.272) A 20-year-old male marathoner has had left sided groin pain for the past 4 weeks. He has continued to maintain his routine running regimen despite the discomfort. Radiograph, bone scan, and MR images are shown in Figures A-D. What is the most appropriate next step in management? Review Topic

QID: 1377
FIGURES:
1

Referral to orthopaedic oncologist

3%

(58/2087)

2

Valgus intertrochanteric osteotomy

1%

(11/2087)

3

Hip arthroscopic evaluation and labral repair

2%

(49/2087)

4

Percutaneous screw fixation

94%

(1954/2087)

5

Irrigation and debridement with course of intravenous antibiotics

0%

(10/2087)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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