Treatment of stress fractures of the femoral neck

Many authors have elaborated on the conservative treatment of stress fractures of the neck and discussed the prerequisites based on clinical and radiologic findings (Jeffery, 1962; Ernest, 1964; Devas, 1965; Erne and Burckhardt, 1980; Kaltsas, 1981; Menoman et al, 1981; Sloan and Holloway, 1981; Ochy and Vogt, 1985; Tountas and Waddell, 1986; Meine, 1991; Kerr and Johnson, 1995; Bucinto et al, 1997; Parker and Tremlow, 1997).

Clinical criteria:

- Complete passive range of motion;

- Active lifting in extension.

Radiologic criteria:

- Good impaction in both projections;

- No displacement.

We believe that these criteria are only valid for the rare compression stress fracture. A distraction fracture without displacement can only be considered during the early phase; but these fractures are only rarely seen at that point. The compression stress fracture consolidates normally without surgical treatment after six weeks of non-weight bearing (Devas, 1965; Erne and Burckhardt, 1980; Menoman et al, 1981; Tountas and Waddell, 1986). In young active patients, in non-cooperating individuals or in instances where pain increases after the initial phase (progression), it is advisable to perform a minimally invasive stabilization with one or two cannulated screws or pins. The pain subsides rapidly after internal fixation and one can allow weight bearing without qualms (Fig. 223).

In our patient population the distraction fractures, be they transverse, lateral or cranial, predominate. In more recent years we stabilized them with two cannulated screws supplemented by a caudal 2 mm two-hole plate. Fractures with a marked displacement and thus a disturbance of head circulation and therefore candidates for an arthroplasty have not been observed by us during this time. Based on the history, however, we presume that some displaced neck fractures seen by us were originally stress fractures; however, at earlier times an elucidation of their pathogenesis had been impossible. Fractures treated by internal fixation always consolidated and we never observed instances of head necrosis secondary to vascular disturbances (Fig. 224).

In the varus position shown in Fig. 224 the lever arm to which the force is applied increases. This lever arm is defined by the distance between the center of the femoral head and Adam's arch; it leads to an increased loading of the third buttressing point. In this case the use of an angle-stable plate is indicated. Today, we use for stabilization of such a fracture a DCD plate, mostly of 120°. A further advantage of the DCD plate is the use of the compression screw that reduces or eliminates the gaping of the fracture. At the same time, it protects against forces causing a displacement (tilting) (see Figs. 145 and 146).

Finally in Fig. 225, we demonstrate a patient where an incorrectly performed surgical procedure was the probable cause of repeated stress fractures (Cserhati, 1991).

Femur Stress Fracture Treatment

Fig. 223. Compression stress fracture.

This 41-year-old patient could not recall any accident. Since two weeks she felt pain in her left hip; a, b. Radiographs show a compression fracture at the level of Adam's arch (arrows); c. Two years after fixation with two cannulated screws the fracture is healed and the patient symptom-free

Fig. 223. Compression stress fracture.

This 41-year-old patient could not recall any accident. Since two weeks she felt pain in her left hip; a, b. Radiographs show a compression fracture at the level of Adam's arch (arrows); c. Two years after fixation with two cannulated screws the fracture is healed and the patient symptom-free

Compression Fracture AdamVarus Left Femoral Neck

Fig. 224. Distraction stress fracture.

This 72-year-old lady complained about an increasing vague pain of her left hip; a, b. Radiographs show a coxa vara most probably the cause of the distraction fracture (arrow). The varus displacement is minimal; c, d. One year after fixation with two screws the fracture has consolidated. Corresponding to the varus position the screws also lie in varus

Femoral Fracture Nail Lateral

Fig. 225. Repeated bilateral stress fractures.

This 56-year-old woman fell at work from the loading platform of a truck and broke her left femoral shaft. She was treated elsewhere with a 9 mm intramedullary Kuntscher nail inserted retrograde. The guide wire was inserted through the fracture site in a cranial direction; a. A hypertrophic non-union developed. She used crutches and came to our institute nine months later; b. We exchanged the nail and after reaming inserted antegrade a 16 mm nail without opening the fracture site; c. Two years later the fracture had healed and the function was good. A shortening of 3 cm was compensated by a lift; the nail was removed; Eleven years later she fell while riding a bicycle and suffered a right femoral shaft fracture. An intramedullary nailing was again done in the same hospital using an identical technique. A technical error occurred intraoperatively: the guide pin was placed too medially and broke through the cortex of the neck. She walked with crutches and came to our institute after five months; d. The nail exceeded the tip of the trochanter by 7 cm causing pain in the right hip (the fracture was not healed); e. After removal of the nail we performed a closed reaming and insertion of a new nail through the base of the neck. She did not complain about her right hip anymore, but due to the use of crutches she overloaded her left hip that became again painful. Seven months later, a fatigue fracture of the left femoral neck was diagnosed. In yet

Fig. 225. Repeated bilateral stress fractures.

This 56-year-old woman fell at work from the loading platform of a truck and broke her left femoral shaft. She was treated elsewhere with a 9 mm intramedullary Kuntscher nail inserted retrograde. The guide wire was inserted through the fracture site in a cranial direction; a. A hypertrophic non-union developed. She used crutches and came to our institute nine months later; b. We exchanged the nail and after reaming inserted antegrade a 16 mm nail without opening the fracture site; c. Two years later the fracture had healed and the function was good. A shortening of 3 cm was compensated by a lift; the nail was removed; Eleven years later she fell while riding a bicycle and suffered a right femoral shaft fracture. An intramedullary nailing was again done in the same hospital using an identical technique. A technical error occurred intraoperatively: the guide pin was placed too medially and broke through the cortex of the neck. She walked with crutches and came to our institute after five months; d. The nail exceeded the tip of the trochanter by 7 cm causing pain in the right hip (the fracture was not healed); e. After removal of the nail we performed a closed reaming and insertion of a new nail through the base of the neck. She did not complain about her right hip anymore, but due to the use of crutches she overloaded her left hip that became again painful. Seven months later, a fatigue fracture of the left femoral neck was diagnosed. In yet

Smith Petersen Nail Removal

another hospital this fracture was treated with a Smith-Petersen nail and plate and cancellous bone screw. Again while overloading the right hip using crutches, the right hip became symptomatic. On account of increasing pain the patient consulted us eight months later; f. Radiographs showed a right sided distraction stress fracture of the femoral neck with gaping (arrow); g, h. At the beginning of surgery while positioning the limb according to our protocol we heard a cracking. A complete fracture was seen on the monitor; it was not displaced as the limb had been fixed on the traction table. As it was too early to remove the intramedullary nail, we inserted next to it three cancellous bone screws and performed a cerclage wiring over their ends thus achieving a tension band effect; i. Ten months later the patients was symptom-free and the right-sided neck fracture had consolidated. As the plate attached to the Smith-Petersen nail gave rise to pain of the left hip, it was removed in the other hospital; j. Six months later, a femoral shaft stress fracture was diagnosed at the site of cortical screw. We performed a DHS plate fixation after removal of the Smith-Petersen nail; k. Subsequently, an undisplaced stress fracture developed at the site of the previous shaft fracture; l. We exchanged the DHS plate against a longer one. Only thereafter (after nine major interventions) did the patient become symptom-free. This case should direct our attention to the sequelae of errors made during the currently popular intramedullary nailing

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  • demi morrison
    What is the treatment for a stress fracture of the femur?
    8 years ago

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