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Updated: Jun 1 2021

Femoral Shaft Stress Fractures

Images shaft stress fracture ap radiograph.jpg shaft stress fractures ct.jpg shaft stress fractures mri.jpg shaft stress fracture mri t1.jpg shaft stress fracture whole body bone scan.jpg shaft stress fracture imn.jpg
  • summary
    • Femoral shaft stress fractures are overuse injuries in which abnormal stresses are placed on trabecular bone of the femoral shaft resulting in microfractures.
    • Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture.
    • Treatment is nonoperative with protected weightbearing in young patients with good bone quality. Prophylactic intramedullary nailing is recommended in patients > 60 or those with osteopenia. 
  • Epidemiology
    • Demographics
      • common in young athletic individuals
    • Risk factors
      • metabolic bone disorder
      • long-term bisphosphonate use
      • may be associated with osteopenia or osteoporosis in endurance athletes
  • Etiology
    • Mechanism
      • occurs through crack propagation in bone
      • repetitive loads that exceed the threshold of intrinsic bone healing
        • repetitive stress on normal bone is a fatigue fracture
        • repetitive stress on abnormal bone is an insufficiency fracture
  • Presentation
    • Symptoms
      • often a history of overuse
      • insidious onset of pain
      • pain during activity is localized to the involved bone
      • pain improves with rest
    • Physical exam
      • focal tenderness and swelling
      • three point fulcrum test elicits pain
        • examiner's arm is used as a fulcrum under the patient's thigh as gentle pressure is applied to the dorsum of the knee with the opposite hand
        • test is positive if pain and apprehension is experienced at the point of the fulcrum
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral
      • findings
        • linear cortical radiolucency
        • periosteal reaction
        • endosteal and cortical thickening
    • CT
      • findings
        • cortical lucency
        • benign-appearing periosteal reaction
    • MRI
      • most sensitive and replacing bone scan for diagnosis
      • views
        • T2-weighted images
          • findings
            • periosteal high signal is the earliest finding
            • broad area of increased signal
        • T1-weighted images
          • reveal linear zone of low signal
    • Technetium Tc 99m bone scan
      • findings
        • focal uptake in cortical and/or trabecular bone
  • Treatment
    • Nonoperative
      • rest, activity modification, protected weight bearing
        • indications
          • most femoral shaft stress fractures
        • technique
          • restrict weight bearing until the fracture heals
          • incorporate cross-training into running programs
    • Operative
      • locked intramedullary reconstruction nail
        • indications
          • prophylactic fixation
            • patients with low bone mass
            • patients >60 years old
          • fracture completion or displacement
        • technique
          • reamed insertion is preferred
  • Prognosis
    • Progression to complete fractures occurs if unrecognized
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