Femoral neck stress fractures

 

Fem neck stressFemoral neck stress fracture MRI

 

Etiology

 

Military

Running athletes

Female triad - anorexia /  amenorrhea / osteoporosis

Osteomalacia / decreased bone mineral density

Coxa vara / coxa valgus

? FAI

 

Femoral stress coxa vara

Femoral neck fracture on right in patient with coxa vara

 

History / Examination

 

No trauma episode

 

Groin pain

- worse with activity

- improves with rest

 

Groin pain with examination

 

Types

 

Compression / inferior neck

- surgery for > 50% fracture line or hip effusion

 

Tension / superior neck

- surgery for any fracture line

 

Xray

- no fracture line

- < 50% fracture line

- > 50% fracture line

- Complete fracture without displacement

- Complete displaced fractures

 

Stress # 1Stress # 2

 

Xray

 

Can be normal

Sclerosis / fracture line

 

Hip stressFem neck stress

Increased sclerosis at inferior neck              Xray demonstrating incomplete fracture of the superior neck

 

CT

 

Fracture line

 

HIp stress CTHip stress CT

CT demonstrating incomplete fracture at inferior neck

 

Superior hip stress fractureHip stress fracture CT

CT demonstrate likely complete fracture, with some displacement

 

MRI

 

Edema / fracture line / hip effusion

 

Stress mRIMRI hip stress

MRI demonstrating edema likely across entire neck

 

Hip Stress FractureHIp Stress FractureHip Stress Fracture 3

MRI demonstrates complete fracture

 

Femoral neck stress fracture MRIMRI completeHip scress #

 

Management

 

Goals

 

Obtain healing

Prevent progression to complete fracture / displacement

 

Non operative

 

Indications

- Tension side edema with no fracture line

- Compression side < 50%

 

Protocol

- 6 weeks non weight bearing

- screen for osteomalacia / BMD

- Vitamin D / Calcium

- minimize activity for 4 - 6 months

- ensure healing on CT / MRI

 

Results

 

Steele et al JBJS Am 2018

- 257 femoral neck stress changes or incomplete fractures treated nonoperatively

- stress changes: no progression treated nonoperatively

- < 50% fracture lines: 27/103 (26%) progression of fracture lines and required surgery

- hip effusion on MRI a risk factor for fracture progression

 

Operative

 

Indications

 

Compression

- involving > 50% neck diameter

- involving < 50% neck diameter with hip effusion

 

Tension side

- fracture line evident

 

Surgery

 

Options

- cannulated screws

- DHS + derotation screw

- +/- minus open reduction

 

Stress ORIF 1Stress ORIF

 

Results

 

Griffis et al Adv Surg Orthop Adv 2018

- 53 military members with incomplete femoral stress fractures

- all treated with surgery

- no progression of fractures to complete

- return to duty 67%

- 17% return in Marine Corp

- 82% return in general Navy

 

Lee et al Arch Orthop Trauma Surg 2003

- 42 military members with displaced femoral neck fractures

- open reduction and fixation

- 28% developed AVN

- associated with delay to treatment and postoperative varus malunion