Updated: 6/1/2021

Femoral Shaft Stress Fractures

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https://upload.orthobullets.com/topic/3111/images/femoral shaft stress fracture ap radiograph.jpg
https://upload.orthobullets.com/topic/3111/images/femoral shaft stress fractures ct.jpg
https://upload.orthobullets.com/topic/3111/images/femoral shaft stress fractures mri.jpg
https://upload.orthobullets.com/topic/3111/images/femoral shaft stress fracture mri t1.jpg
https://upload.orthobullets.com/topic/3111/images/femoral shaft stress fracture whole body bone scan.jpg
https://upload.orthobullets.com/topic/3111/images/femoral 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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