Review Question - QID 210230

Magnetic resonance imaging (MRI) reveals a compression-sided femoral neck fracture. The best initial step in treatment would be weight-bearing restrictions with crutches.

Stress fractures of the femoral neck can occur in younger, active patients or elderly, osteoporotic patients and may be located on the compression or tension side of the femoral neck. In the more common compression stress fractures, the injury begins at the inferior cortex of the femoral neck. The tension stress fracture starts in the superior cortex of the femoral neck and may advance across the femoral neck as a fracture line perpendicular to the axis of the femoral neck. Management depends on fracture location. Nondisplaced stress fractures of the femoral neck localized on the compression side spanning less than 50% of the femoral neck may be treated nonoperatively with protected weight bearing and close observation for 6–8 weeks. Compression sided fractures spanning more than 50% of the femoral neck require internal fixation. Nondisplaced fractures on the tension side of the femoral neck are at increased risk for fracture displacement and require internal fixation. Operative fixation consists of percutaneous placement of cannulated screws.

Florschutz et al. performed a review of femoral neck fractures. They report that stress fractures of the femoral neck should warrant a thorough endocrine workup to detect and treat any underlying metabolic bone pathologies. Younger patients should be educated on appropriate training activities.

Boden et al. review high-risk stress fractures. They report that these fractures develop as the hip musculature becomes fatigued with prolonged activity and subsequently loses its protective shock absorptive effects. Intrinsic factors, such as coxa vara and osteopenia, also may predispose the femoral neck to injury. They conclude that MRI should be obtained in all patients in which a stress fracture of the femoral neck is suspected.

Figure A is a T1-weighted coronal MRI demonstrating a compression-sided femoral neck fracture. Figure B is a T2-weighted coronal MRI demonstrating the same. Figure C is a T2-weighted axial MRI demonstrating edema within the femoral neck. Illustration A depicts the tension and compression sides of the femoral neck.

Incorrect Answers:
Answer 1: Tension-sided femoral neck fractures should be treated with operative fixation given their high risk of displacement.
Answer 2: This is a compression-sided femoral neck fracture, not a tension-sided fracture.
Answer 3: Compression-sided femoral neck fractures are initially treated non-operatively if it involves < 50% of the femoral neck.
Answer 5: Though complete femoral neck stress fractures or compression-sided femoral neck fractures involving > 50% of the neck should be treated with surgical fixation, this is not a complete femoral neck fracture.