Stress Reaction Femur

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Stress fractures of the femur in runners may occur in the femoral neck, trochan-teric and subtrochanteric region, and femoral shaft. These injuries are often not considered in the initial presentation, and a high index of suspicion must be maintained. Patients commonly present with hip, groin, gluteal, thigh, or knee pain, depending on the location of the injury [18,72,73].

In a study by Clement and colleagues [72], 71 patients who had 74 stress fractures of the femur were studied. Nearly 95% were runners. Forty-six percent had anterior thigh pain, 45% had hip pain, and 8% had groin pain. Pain could be reproduced in 70% of patients when they were asked to hop on the affected limb. Bone scans showed a distribution of stress fracture location as 53% in the femoral shaft, 20% in the lesser trochanter, 15% in the intertrochanteric region, 11% in the femoral neck, and l% in the greater trochanter. Only 24% of the 46 plain films acquired were abnormal. The average time to diagnosis was 6.6 weeks. The average time to recovery was 10.4 weeks [72].

In general, stress fractures of the femoral neck may occur along the medial or lateral margin of the neck (Fig. 11A, B). Distraction or tension stress fractures tend to occur along the lateral femoral neck in older patients, whereas compression stress fractures occur along the medial femoral neck, and tend to occur in younger, active patients. Patients typically present with activity related pain, and pain is often reproduced with passive range of motion, particularly internal rotation [74]. Patients commonly present with hip, groin, gluteal, thigh, or knee pain [72,74]. A high clinical suspicion is required in athletes presenting with exertional pain in these areas and with hip pain in extreme ranges of motion. Stress fractures may progress to complete fractures, and complete fractures may displace, which significantly worsens the long-term outcome. The average delay in diagnosis in other series is reported up to 14 weeks, which can result in a nondisplaced fracture advancing to displacement. The displacement of femoral neck fractures is the main determinant of prognosis. Displaced fractures result in a 60% reduction in patient activity level in sports. There is an associated 30% risk of avascular necrosis of the femoral head [75].

Femoral neck stress fractures may be bilateral. Voss and coworkers [76] reported a case of bilateral stress fractures of the femoral neck in a 30-year-old amenorrheic patient who had low caloric intake. Stress fractures of the femoral neck in children who have open capital femoral epiphysis are very rare, but

Femoral Neck Stress Fracture

Fig. 11. 72-year-old physician with a femoral neck stress fracture who developed right hip pain rehabilitating on a treadmill following a myocardial infarction. (A) Axial CT. Nondisplaced fracture line is seen in the medial femoral neck (arrow). (B) Coronal T1-weighted SE. There is vertically oriented low T1 signal intensity in the medial femoral neck consistent with fracture plane (arrow).

Fig. 11. 72-year-old physician with a femoral neck stress fracture who developed right hip pain rehabilitating on a treadmill following a myocardial infarction. (A) Axial CT. Nondisplaced fracture line is seen in the medial femoral neck (arrow). (B) Coronal T1-weighted SE. There is vertically oriented low T1 signal intensity in the medial femoral neck consistent with fracture plane (arrow).

have been reported. One reported case has been published of a 8-year-old child who had bilateral femoral neck fractures [19].

Diagnosis is most often made on the basis of clinical and radiographic information. Conventional radiographs are often normal, and MRI has proven valuable in the diagnosis of these injuries [77]. MRI of stress response typically shows intramedullary low T1 signal and corresponding increased T2, fat-saturated or STIR signal intensity, and may show enhancement of the corresponding marrow as well as surrounding soft tissues after contrast administration.

An actual stress fracture will show the above findings associated with stress response, with the additional finding of a low T1, low T2 signal intensity line extending through the cortex representing the fracture plane (Fig. 12A-C) [24,34-36].

Treatment of femoral stress fractures depends on the location, character, and extent of the stress fracture. Early stress reaction and nondisplaced compression-type stress fractures of the femoral neck may be treated conservatively with non-weight bearing and frequent radiographic follow-up. Surgical fixation is required for tension-type stress fractures, larger cortical defects, or displaced fractures [3].

Stress fractures of the femoral shaft most commonly occur in the proximal third of the femur. They may also occur in the mid and distal thirds. In these locations they may present with anterior thigh pain, vague thigh pain, and diffuse tenderness (Fig. 13).

Clinical and radiographic correlation cannot be overemphasized. In one reported case [18], a 42-year-old runner's anterior thigh pain was treated as a muscle strain. Symptoms persisted and the patient underwent an MRI of the knee, which revealed a mild degenerative meniscal tear that was then assumed to be a cause of femoral pain radiating to the knee. During positioning of the patient

Stress Reaction Femur

Fig. 12. 19-year-old male basketball player running sprints. (A) Conventional radiograph shows a healing stress fracture midfemur with nonaggressive periosteal reaction (arrow). (B) Coronal T1 SE. Healing stress fracture midfemur with nonaggressive periosteal reaction (arrow). (C) Coronal STIR. Healing stress fracture mid femur with nonaggressive periosteal reaction, and periosteal, endosteal, and soft-tissue edema (arrow).

Fig. 12. 19-year-old male basketball player running sprints. (A) Conventional radiograph shows a healing stress fracture midfemur with nonaggressive periosteal reaction (arrow). (B) Coronal T1 SE. Healing stress fracture midfemur with nonaggressive periosteal reaction (arrow). (C) Coronal STIR. Healing stress fracture mid femur with nonaggressive periosteal reaction, and periosteal, endosteal, and soft-tissue edema (arrow).

Femoral Shaft Stress Reaction Images
Fig. 13. Longitudinal femoral stress fracture. 19-year-old with thigh pain related to running. Coronal T1 SE image shows thin low signal intensity longitudinal line in the femoral diaphysis consistent with a longitudinal stress fracture (arrow).

in the operating room for arthroscopy, a complete fracture occurred through an undiagnosed supracondylar stress fracture, which was retrospectively manifested by intramedullary and periosteal edema on the prior MRI [18].

Conservative treatment is often successful in the treatment of these fractures. Often athletes can return to activity in 8 to 14 weeks [78].

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Responses

  • niklas
    How long for a femur stress reaction to heal?
    8 years ago
  • Dalila
    Where would hip hurt with stress fracture?
    8 years ago
  • neera
    What are stress resonses on the femur?
    7 years ago
  • pasquale
    What is a grade 3 femoral stress reaction?
    7 years ago
  • Rudi
    What is a femoral stress response?
    7 years ago
  • AMARANTO CREMONESI
    Is a stress reaction a fracture?
    7 years ago
  • folco clayhanger
    What is a stress reaction to the hip bone?
    6 years ago
  • kristian
    What is atypical stress reaction to femur?
    6 years ago
  • Agatino
    How to overcome stress reaction in femurs?
    3 years ago
  • awet senay
    How to cure stress reaction of the femurs?
    3 years ago
  • corinna
    What is stress reaction of proximal femur?
    2 years ago
  • diana achen
    Are stress reactions common in femoral disphyses?
    1 year ago
  • Ruth
    How to treat femoral stress reaction?
    1 year ago
  • Neave
    How to treat stress reaction femur?
    1 year ago
  • kim
    Can your running form cause a stress reaction to your femur bone?
    3 months ago
  • TOYA
    How long does it take to resolve a stress reaction in the femur?
    3 months ago
  • harvey martin
    How long to heal stress reaction in medial femoral condyle?
    3 months ago
  • gundabald
    What is a stress response of the greater trochanter?
    2 months ago
  • GRINGAMOR
    How nad does a stress fracture in femoral neck hurt?
    28 days ago

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