Updated: 10/6/2016

Femoral Shaft Stress Fractures

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https://upload.orthobullets.com/topic/3111/images/femoral shaft stress fractures mri.jpg
https://upload.orthobullets.com/topic/3111/images/femoral shaft stress fracture whole body bone scan.jpg
Introduction
  • Overuse injuries in which abnormal stresses are placed on trabecular bone resulting in microfractures
  • 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
  • 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
  • Prognosis
    • progression to complete fractures occurs if unrecognized
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
 

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