Femoral Neck Stress Fracture

Aka: Femoral Neck Stress Fracture

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II. Pathophysiology

  1. As with other Stress Fractures, overuse injury more common in female athletes
  2. Images
    1. femoralNeckStressFractureForces.jpg

III. Risk Factors

  1. See Stress Fracture
  2. Similar risks to Pubic Ramus Stress Fracture (Military recruits, Distance runners and Dancers age 20 to 30 years old)
    1. Associated with a sudden increase in Exercise intensity or distance
  3. Insufficiency Fracture risks
    1. Relative Energy Deficiency in Sport (RED-S)
    2. Postmenopause
    3. Female gender
    4. Delayed Menarche
    5. Femoral acetabular impingement
    6. Low Vitamin D Level
    7. Smoking
    8. Metabolic conditions (e.g. Osteoporosis, Hyperparathyroidism, renal disease)

IV. Symptoms

  1. Groin Pain or anterior thigh pain, or lateral thigh or buttock pain
  2. Provoked by activity (weight bearing)
  3. Relieved with rest (but may cause night pain)

V. Signs

  1. Antalgic Gait
  2. Provocative maneuvers resulting in pain
    1. Internal hip rotation
    2. Weight bearing
    3. Log Roll Test (Freiberg Test, Passive Supine Hip Rotation)

VI. Imaging

  1. Hip XRay
    1. XRay changes lag symptoms by 2-4 weeks
    2. Cortical density loss, cortical thickening or actual Fracture line may be seen
  2. MRI preferred over nuclear bone scan
    1. High Test Sensitivity (similar to bone scan)
    2. High Test Specificity (better than bone scan)

VII. Management

  1. Early diagnosis and management is critical to avoid a devastating complete Hip Fracture
    1. Initiate non-weight bearing and avoidance of lower extremity activity while definitive imaging is pending
  2. Risk Modification
    1. See Stress Fracture
    2. Image the opposite hip if Stress Fracture is found (bilateral Hip Stress Fractures are common)
  3. Inferior Femoral Neck Stress Fractures (medial, compressive or compression side)
    1. Consult orthopedic surgery
    2. Period of strict non-weight bearing and crutch use
      1. Gradual progression to weight bearing activity starts only after pain improves and imaging demonstrates healing
      2. Typical weight bearing progression occurs over a 4 to 6 week period
    3. Conservative management (as long as involves <50% of cortex)
    4. Return to Running and sport in 8-12 weeks
  4. Superior Femoral Neck Stress Fractures (lateral, tensile or tension side)
    1. Risk of complete Fracture or Hip Avascular Necrosis
    2. Consult orthopedic surgery urgently
      1. Consider percutaneous screw fixation

VIII. Complications

  1. Complete, displaced Hip Fracture (if not diagnosed early)
  2. Nonunion Fracture
  3. Avascular Necrosis

IX. References

  1. Shahideh (2013) Crit Dec Emerg Med 27(9):10-18
  2. Morelli (2001) Am Fam Physician 64(8):1405-1414 [PubMed]
  3. Schroeder (2022) Am Fam Physician 106(6): 675-83 [PubMed]

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