Femoral Stress Fractures Research Articles

Bilateral neck of femur stress fracture secondary to osteopetrosis treated with dynamic hip screw

Osteopetrosis, a rare hereditary bone disorder, is characterized by increased bone density due to defective osteoclast-mediated bone resorption. This condition often leads to skeletal fragility, resulting in recurrent fractures despite increased bone mass. Among these, stress fractures of the femoral neck pose a unique challenge where conventional management may not be optimal. Valgus osteotomy offers a viable surgical intervention to realign the mechanical axis, thereby reducing stress on the femoral neck and facilitating healing. This paper reviews the pathophysiology of osteopetrosis, its impact on fracture healing, and the role of valgus osteotomy in managing femoral neck stress fractures in osteopetrotic patients.

Tenofovir Induced Bilateral Femoral Neck Stress Fracture

Case: A 47 year old male, came with history of bilateral hip pain ,insidious in onset gradually progressive, with difficulty in walking unassisted since 2 years. No history of fall/ trauma. Patient is known case of retroviral disease and on ART (TLE regimen ) since 2 years. Relevant radiographs were done and was diagnosed with bilateral neck of femur stress fracture (Tenofovir induced) associated with hypophosphatemia. ART regimen was changed to (Abacavir ,Lamivudine , Dolutegravir) . Patient on regular follow up every 2 months with serial radiographs. . On 6 months follow up patient is symptomatically improved with healing bilateral neck of femur stress fracture.

Delayed presentation of a bilateral neck of femur stress fracture with an excellent outcome following closed reduction treatment: Case report

Delayed presentation of a bilateral neck of femur stress fracture with an excellent outcome following closed reduction treatment: Case report

Femoral Neck Shaft Angle Measurement for Differentiating Femoral Head Stress Fracture from Avascular Necrosis.

The study aimed to evaluate whether the measurement of Femoral Neck Shaft Angle (FNSA) can be helpful in differentiating femoral head Stress Fracture (SF) from Avascular Necrosis (AVN). From September 2019 to April 2022, sixty-four patients [median age 32.0 years, interquartile range (IQR) 23.0-39.0 years] who underwent both hip radiograph and Magnetic Resonance Imaging (MRI) and diagnosed as femoral head SF or AVN were included in our retrospective study. Patients were divided into as having either femoral head SF (n = 34) or AVN (n = 30). The FNSA was measured in anteroposterior hip radiography. Continuous values were compared using the Mann-Whitney U test. The assessment of the predictive value of FNSA for femoral head SF was performed by Receiver Operating Characteristic (ROC) analysis. The FNSA was significantly higher in patients with SF (median 133.5°, IQR 128.0-136.7°) than those with AVN (median 127.5°, IQR 124.0-132.0°) (p = 0.001). In addition, the FNSA was significantly higher in SF femurs (median 134.8°, IQR 129.2-137.4°) than in contralateral normal femurs (median 127.1°, IQR 124.3-132.5°) in patients with unilateral femoral head SF (n = 30) (p < 0.001). In ROC analysis, the sensitivity, specificity, and Area Under the Curve (AUC) for predicting the femoral head SF were 77.3%, 63.3%, and 0.785 (95% confidence interval: 0.666-0.905), respectively, at a cutoff of 130.2°. Increased FNSA was associated with femoral head SF; thus, measurement of FNSA could be helpful for differentiating femoral head SF from AVN.

Distal Femoral Stress Fractures Has High Operation Rates in Adolescent and Young Adult Athletes.

Although stress fractures of the distal femur are rare, symptoms can overlap with other peri-articular knee pathology, delaying diagnosis. Untreated stress fractures have the potential to progress into completed fractures with a higher likelihood for requiring surgery and longer recovery times in otherwise healthy adolescents and young adults. This case series represents the largest cohort of adolescent athletes with distal femoral stress fractures who presented with activity-related knee pain. Patients treated nonoperatively and operatively for metaphyseal distal femur stress fractures at a tertiary referral center over a four-year period were retrospectively identified from the medical record. Eight patients (mean age 16.8y; range 14 to 22y; 87.5% male; mean body mass index [BMI] 20.9) with a total of 10 distal femur stress fractures were identified. All patients were involved in competitive sports or military training. There was an average of 3.8 encounters with a medical provider between presentation with activity-related knee pain and diagnosis with distal femur stress fracture. All except 1 patient (87.5%) were initially incorrectly diagnosed with another type of peri-articular knee pathology. Six stress fractures (60%) were treated conservatively with protected weight bearing, activity modification, and gradual return to activity. Four completed stress fractures (40%) required operative fixation-3 healed uneventfully, while 1 had an asymptomatic delayed union. Vitamin D insufficiency (<30ng/mL) was identified in 7 of 8 patients (87.5%) and 3 patients (37.5%) had an underweight BMI (<18.5). The mean clinical follow-up was 13.1 weeks (range, 2.8 to 32.0wk). High clinical suspicion for distal femoral stress fractures is needed to avoid misdiagnosis or delayed diagnosis in young, active individuals with activity-related knee pain refractory to conservative management. In this patient population, activity-related knee pain recalcitrant to activity modification, rest, and physical therapy warrants further workup with magnetic resonance imaging and orthopaedic evaluation. Though rare, misdiagnosis can result in catastrophic fractures with prolonged rehabilitation needs. An open line of communication and streamlined access for referral between primary care providers and orthopaedic surgeons is critical in preventing misdiagnosis and delayed treatment. Furthermore, the treatment of concomitant metabolic disorders and nutritional deficiency should not be neglected when treating distal femoral stress fractures. Level-IV (case series).

Late Periprosthetic Femoral Stress Fracture Associated with Extra-articular Deformity in a Patient with Fibrous Dysplasia: A Case Report.

In the setting of a total hip arthroplasty performed in a patient with a proximal femoral deformity, atraumatic periprosthetic femoral stress fracture may arise as a complication. We report a rare case of a late periprosthetic femoral stress fracture around a cemented stem in a patient with a history of fibrous dysplasia of the proximal femur. After a 10-year uneventful period, the patient complained about a subtle, subacute pain in his left thigh induced by exercise but not with daily axial load. Diagnosis of a nondisplaced, incomplete (i.e., only compromising the lateral femoral cortex) periprosthetic femoral stress fracture was made with plain radiographs, blood work, and bone scintigraphy. Surgical treatment consisted of a minimally invasive plate osteosynthesis bridging the femoral deformity plus percutaneous osteoperiosteal decortication. At 5-year follow-up, the patient was asymptomatic with full return to physical activity, with radiographs evidencing callus formation. Stress fractures around well-fixed femoral stems, while infrequent, should be addressed in patients with a history of severe proximal femur deformity experiencing atraumatic thigh pain.

Distal femur stress fracture: A unique case presentation in a youth rower

Department of Emergency Medicine, Department of Orthopaedic Surgery and Sports Medicine, University of Florida College of Medicine, Gainesville, FL Financial Disclosures: The author reports no conflicts of interest. Correspondence to Joshua Altman, MD, CAQSM, University of Florida College of Medicine, Department of Emergency Medicine, Department of Orthopaedic Surgery and Sports Medicine, Gainesville 32610, FL Tel: +352-265-5911; fax: +352-265-5606; e-mail: [email protected].

How Advancement in Bone Science Should Inform the Examination and Treatment of Femoral Shaft Bone Stress Injuries in Running Athletes.

Stress fractures likely have a 1-2% incidence in athletes in general. In runners, a more vulnerable population, incidence rates likely range between 3.2 and 21% with female runners having greater susceptibility. The incidence of femoral shaft stress fractures is less well known. New basic and translational science research may impact the way clinicians diagnose and treat femoral stress fractures. By using a fictitious case study, this paper applies bone science to suggest new approaches to evaluating and treating femoral shaft stress fractures in the running population.

Clodronate in a case of femoral head stress fracture in a male with idiopathic osteoporosis: complete recovery with a 6-year follow-up

article: Clodronate in a case of femoral head stress fracture in a male with idiopathic osteoporosis: complete recovery with a 6-year follow-up - Medicina dello Sport 2022 December;75(4):615-9 - Minerva Medica - Journals

Atypical Femoral Stress Fracture with Uncommon Location and Mechanism of Injury: A Case Report

Atypical Femoral Stress Fracture with Uncommon Location and Mechanism of Injury: A Case Report

Femoral neck stress fracture in a middle aged female: A case report

Stress fractures of the femoral neck are uncommon and may go unnoticed at first. Stress fractures are most commonly seen in athletes as overuse injuries. A 49 year old house wife presenting with continuous right knee pain aggravated by physical activity was diagnosed as Fullerton and Snowdy type two neck of femur stress fracture and was treated conservatively. If a stress fracture is not treated, it might deteriorate. It can cause poor healing, and even require surgery. Timely management is the key.

Hip Pain-Cross Country

Title:Hip Pain-Cross Country Keywords:Hip pain, stress fracture, femur HISTORY: A 15 year old female cross country runner presented with 3 weeks of right groin and knee pain. She started cross country for the first time this year and had a significant increase in her mileage, from 2 miles per day over the summer up to 6 miles per day with the start of the season. On presentation, patient was experiencing pain with both walking and running and pain improved with rest. She had been on crutches for one week and had minimal improvement in her pain. She described the pain as radiating down her leg. There was no numbness, tingling or weakness in her leg. PHYSICAL EXAMINATION: Patient was alert and in no acute distress at rest. She had an antalgic gait. Right hip and knee had no soft tissue swelling or bruising. No tenderness over the pelvic region, adductors or abductors, quadriceps or hamstrings. No pain over the knee joint lines. Full, painless range of motion of the hip and knee. 4+/5 strength to hip adduction with mild pain. Full strength in all other planes without pain. Pain with right leg hop test. DIFFERENTIAL DIAGNOSIS: 1. Adductor strain 2. Apophyseal Avulsion Fracture 3. Stress fracture TESTS AND RESULTS: Radiographs, right knee, AP, lateral and sunrise-Normal alignment, no acute bony abnormalities, the patient has reached skeletal maturityRadiographs, right hip, AP pelvis and frog-leg hip-No acute bony abnormalities, normal alignmentMRI, right femur-Stress fracture of the femoral diaphysis with associated marrow edema and periosteal edema FINAL/WORKING DIAGNOSIS: Stress fracture of the femoral diaphysis TREATMENT AND OUTCOMES: 1. Non-weight bearing on crutches for 3 weeks followed by a gradual transition to one crutch and then full weight bearing when she was pain free. 2. Rehab with the school athletic trainer as well as physical therapy 3. With clinical and radiographic signs of healing at week 7, patient progressed to the stationary bike and then elliptical over the next three weeks. 4. She started jogging at week 11 and slowly added 10% distance/intensity per week 5. Athlete returned to her winter sport, basketball, 12 weeks after injury and continues to do well

Progression of atypical femur stress fracture after discontinuation of bisphosphonate therapy

Atypical femur fracture (AFF) is an uncommon complication of long-term bisphosphonate use, but the risk declines substantially after treatment cessation. We report a case of a 70-year-old woman with osteopenia treated with alendronate for 9 years who presented with right mid-thigh pain and radiographic findings of focal lateral cortical thickening in the right mid-femur and lateral cortex irregularity in the proximal-mid left femur. Alendronate was discontinued, but she remained on estrogen for menopausal symptoms. Four years later, a horizontal linear translucent defect was seen in the right mid-femur area of cortical hypertrophy, consistent with an incomplete AFF. The patient underwent prophylactic intramedullary rodding of the right femur and estrogen was discontinued. Three years later (7 years after initial presentation), the cortical irregularities in the left femur were more prominent and three small horizontal linear translucent defects were now evident, consistent with early incomplete atypical fracture development. The patient also suffered a wrist fracture. She was treated with teriparatide for 1.5 years with resolution of the translucent defects in the left but not the right femur, although abnormal thickening of the lateral cortex persisted in both femurs. Our case demonstrates incomplete atypical femur fracture progression in a patient with long-term bisphosphonate exposure, even after treatment cessation. These findings highlight the importance of follow-up for patients who develop diaphyseal femur stress fractures and the potential for early healing with anabolic therapy. This case also demonstrates the challenge in managing older patients with incomplete AFF at risk for progression to complete AFF and osteoporotic fracture.

Compartment Syndrome: an Acute Femoral Stress Fracture in a Young Male Athlete

The incidence of an acute compartment syndrome (ACS) of the thigh is less than 1%. It is most common in the setting of muscle overuse or muscle injury, as well as secondary to trauma, such as a femoral fracture. We present a case of an ACS in a young, healthy, and semiprofessional athlete with normal coagulation who sustained an acute stress fracture of the distal femur. After the initial fracture osteosynthesis, the patient suffered from a compartment syndrome in the right anterior aspect of the distal thigh. Following rapid surgical fasciotomy, the case was uneventful, and he returned to his preinjury sport level without any neurological consequences. This case confirms that ACS in the thigh is rare, but mainly occurs in young males with a large muscle mass due to participation in various athletic programs. We hypothesize that constant muscle over-usage primes for a larger amount of contused and protruding muscle mass in the small femoral compartment. Hence, the fatigued muscle subjects the bone to an increased mechanical force resulting in an overloading process. This ensues the accumulation of femoral microfractures and primes for the occurrence of an increased rate of stress fractures and an ACS in the thigh.

Atypical periprosthetic femoral fractures of the hip: characterisation of three cases.

Long-term use of bisphosphonates (BPs) has been associated with a specific type of tensile side femoral stress fracture known as Atypical Femoral Fracture (AFF). Theoretically periprosthetic femoral fractures (PFF) should be excluded from the diagnosis of AFF. However, emerging evidence correlates prolonged BPs use with the occurrence of a type of PFF with an atypical pattern (atypical PFF, APFF). The aim of the present study is to report 3 cases of APFF treated at a single centre. Clinical and radiographic records of PFF that occurred between January 2016 and August 2018 were retrospectively reviewed. All patients meeting the American Society for Bone and Mineral Research (ASBMR) criteria for definition of PFF were included. Management strategies for APFF and patient outcomes, including fracture healing and hip function (assessed by the Oxford Hip Score [OHS]) were collected. 3 patients in the study period were identified as APFF (1 incomplete, 2 complete). All patients were females with a mean age of 83.3 years. All patients were treated with lateral plating. The application of a contralateral strut allograft resulted in fracture healing in cases of complete fractures. Mean OHS at final follow-up was 34.3. Despite occurring around a hip stem like PFF, APFF had peculiar clinical and radiographic features, making them more similar to AFF. Therefore, the orthopaedic surgeon should also consider the natural history and healing problems associated with AFF prior in order to choose the most appropriate management for APFF.

Femoral neck shaft angle in relation to the location of femoral stress fracture in young military recruits: femoral head versus femoral neck stress fracture

ObjectiveTo evaluate the influences of the femoral neck shaft angle (FNSA) on the location of the femoral stress fracture and to assess the potential differences in FNSA between fractured and normal femurs.Materials and methodsThirty-seven patients with femoral stress fractures who underwent both plain hip radiographs and MRI, from January 2016 to September 2019, were retrospectively included. Patients were classified as having either femoral head stress fracture (group A, n = 26) or femoral neck stress fracture (group B, n = 11). The FNSA was measured in anteroposterior (AP) hip radiograph. The Mann-Whitney U testing was used to compare the continuous values between the two groups. A receiver operating characteristic (ROC) analysis was used to evaluate the value of FNSA for predicting the risk of femoral stress fracture.ResultsThe FNSA was significantly higher in group A (median 135.9°, range 129.5–138.6°) than group B (median 124.3°, range 119.5–129.0°) (p < 0.001), but there were no significant differences in other clinical factors. Furthermore, the FNSA was significantly higher at the fractured femurs (median 135.9°, range 129.9–138.6°) than contralateral normal femurs (median 127.9°, range 123.8–132.1°) in the patients with unilateral femoral head stress fracture (n = 22) (p < 0.001). The ROC analysis revealed that the area under curve (AUC), sensitivity, and specificity for predicting the risk of femoral head stress fracture were 0.807, 72.7%, and 68.2%, respectively, at a FNSA cutoff of 131.0°.ConclusionFNSA was associated with the location of the femoral stress fracture. In addition, FNSA could serve as a predictive factor for the risk of femoral head stress fractures.

Battling chronic pain and learning self-advocacy: the long journey of becoming pain free

I had returned to running for about 6 months following a stress fracture in my left femur when I started noticing pain high up in my right hamstring. It got...

Posterior Thigh Injury-Tennis

HISTORY: A 76-year-old male was sprinting for the ball one hour into playing singles tennis with a score of 6-6 when he developed acute onset right posterior mid-thigh pain. He denied an audible “pop.” He stopped playing, took ibuprofen, and applied ice upon returning home. He continued to rest and apply ice. Eight days later, he presented to the outpatient sports medicine clinic with improved pain rated 1-2/10, but with worsened swelling and bruising of the right distal posterior thigh. He denied back pain, hip pain, lower extremity numbness, tingling, or weakness. He denied a history of prior hamstring injury. He typically plays doubles tennis three times/week for two hours at a time. This was his second time playing singles this year. PHYSICAL EXAMINATION: Examination revealed bruising along the popliteal fossa and distal hamstring on the right. There was palpable swelling and mild tenderness along the medial aspect of the posterior mid-thigh on the right. There was no tenderness to palpation of the ischial tuberosity. Knee flexion strength was 4/5 on the right, 5/5 on the left. Gait was non-antalgic. There was pain with resisted right knee flexion at 135 degrees, with lesser discomfort at 90 and 45 degrees. Bilateral lower extremities were warm with intact sensation and +2 patellar and achilles reflexes. DIFFERENTIAL DIAGNOSIS: 1. Hamstring muscle strain or tear 2. Hamstring tendon avulsion injury 3. Femoral stress fracture 4. Adductor magnus strain 5. Referred pain from the lumbosacral spine, hip joint, or sacroiliac joint 6. Ischial bursitis TESTS AND RESULTS: Right Hamstring Ultrasound: -Hypoechogenicity of the right semimembranosus muscle consistent with partial tear -Intramuscular calcification in the area of the tear MRI Pelvis Without Contrast: -Suggestion of grade 2 hamstring muscle strain centered near the central myotendinous complex of one of the hamstring tendons, likely the semimembranosus FINAL WORKING DIAGNOSIS: Partial tear of the semimembranosus muscle with calcification TREATMENT AND OUTCOMES: 1. Rest for 2 weeks post-injury. 2. Walk and cycle if tolerated 3-4 weeks post-injury. No tennis. 3. Started physical therapy 4 weeks post-injury for progressive hamstring strengthening and return to tennis and exercise.

Hip And Thigh Pain In A Runner

HISTORY: A 46-year-old male runner with a history of right-sided L3 radiculopathy presented with one month of recurrent right hip and thigh pain. He denied any trauma, inciting event, or recent alteration in his running regimen. Pain was described as stabbing, and localized to his right lateral hip with radiation down his anterior thigh to his knee. He also reported numbness and tingling down his anterior thigh to the knee. Recently, he experienced an incident of sudden bowel urgency with near bowel incontinence. No bladder incontinence or perineal numbness. He has a history of chronic gastroesophageal reflux disease and has taken omeprazole daily for 10 years. PHYSICAL EXAMINATION: Full and symmetric lower extremity strength except for 4/5 with right hip abduction. Sensation intact to light touch at his hips, thighs, groin, buttocks, and scrotal region. No tenderness at the lumbar paraspinals, buttock musculature, greater trochanters, or anterior hip. Negative straight leg raise and reverse straight leg raise. Full, non-painful range of motion with lumbar flexion and extension. No pain with resisted hip flexion, or passive end range hip flexion. Negative FABER, FADIR, femoral nerve stretch. DIFFERENTIAL DIAGNOSIS: 1. Recurrent Upper Lumbar Radiculopathy 2. Hip Flexor Tendinopathy 3. Iliotibial Band Syndrome 4. Hip Osteoarthritis 5. Femoral Stress Fracture TEST AND RESULTS: 1. Right Hip X-Ray:- Mild osteoarthritis of bilateral hips.- Wedge sclerosis and mild periostitis of the medial aspect of the right femoral neck. 2. Lumbar Spine X-Ray:- Mild intervertebral disc height loss at T12-L1, L2-L3, and L5-S1. 3. Right Hip MRI:- Linear T1 focus with surrounding STIR hyperintensity along the medial aspect of the right femoral neck, compatible with a stress fracture. 4. Lumbar Spine MRI:- Right foraminal/extraforaminal disc protrusion at L3-L4. 5. DEXA Scan: - No signs of significant osteopenia or osteoporosis at the spine or hips. 6. Calcium, 25-OH Vitamin D, Parathyroid Hormone levels: Normal FINAL WORKING DIAGNOSIS: Right femoral neck stress fracture, potentially due to chronic proton pump inhibitor use TREATMENT AND OUTCOMES: 1. Referral to orthopedic surgery. 2. Toe-touch weight bearing for 6 weeks. 3. Discontinuation of omeprazole. 4. Consideration of future referral to endocrinology.

Let’s Talk About Stress

HISTORY: A 32 year old Female nurse presented to the sports medicine clinic with complaint of left hip pain after she was lifting a patient and twisted her left hip internally. She felt sudden sharp pain over the lateral and anterior hip that radiated into the groin. Pain was made worse with movement and improved with rest and she rated the pain as 7 out of 10 after the injury. Her symptoms continued with little improvement over a few weeks resulting in a antalgic gait favoring the left side. She rates her pain as 6 out of 10 on VAS at presentation. She tried ibuprofen with little relief, has had no imaging or treatment. She runs 3 miles 3 to 5 times per week prior to the injury. She had a history of irregular menses for many years. PHYSICAL EXAMINATION: Examination in the clinic revealed a slim female with no swelling or bruising over the left hip. She had tenderness to palpation over the anterior groin and greater trochanter on the left side. She had limited internal rotation of the hip and preserved external rotation. Her strength was preserved and she was neurovascularly intact. She had positive log roll, FADIR and negative FABER. She had an antalgic gait favoring the left side. DIFFERENTIAL DIAGNOSIS: 1.Labral Tear 2.Femoroacetabular impingement (FAI) 3.Stress fracture of the femoral neck 4.Hip flexor strain 5.Female athlete triad TEST AND RESULTS: Left hip xrays: 1.Preserved joint space with mild pincer deformity suggesting FAI. No fractures or dislocations noted. MRI Arthrogram of Left Hip: 1.Significant marrow edema and contusion involving a large portion of the femoral neck with a non-displaced stress fracture involving the medial left femoral neck. 2.No labral tear noted. Left Hip Xray 1 week post operatively 1.Three compression screws in the femoral head and neck with adequate alignment and no signs of migration or loosening of the screws. FINAL/WORKING DIAGNOSIS: Left femoral neck non-displaced stress fracture with workup for female athlete triad TREATMENT AND OUTCOMES: 1. Patient made non weight bearing with crutches 2. Patient was given options of surgical or conservative management of her compression-sided fracture and chose to pursue surgical route given the fracture extended approx. 50% across the femoral neck and her level of activity prior to the fracture. 3. Closed reduction with percutaneous pinning of the left hip 4. Using a walker for immobilization she was made 25% weight bearing 5. 1 week post operatively her pain was improving and she was compliant with weight bearing status, 6. 2 weeks post operatively she continues to improve, she is advanced to 50% weight bearing status using walker and starting physical therapy. She remains off of work as a nurse. 7. Plan to return to work three to four months post operatively.