FEMORAL STRESS FRACTURES

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Stress fractures are common overuse injuries frequently seen in athletes and military recruits. Stress fractures are subdivided into insufficiency and fatigue fractures—insufficiency fractures occur from normal muscular activity on deficient bone; fatigue fractures are due to excessive, repetitive stresses on normal bone. This review article focuses on fatigue fractures of the femur, the fourth most common site of stress fractures in athletes. Given the increasing interest in physical fitness over the past two decades, it is important for the sports medicine physician to understand the origin, diagnosis, treatment, and prevention of these injuries.

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ORIGIN

Stress fractures may occur when there is an imbalance between bone injury and bone remodeling. Bone reacts to stress by early osteoclastic activity followed by strengthening osteoblastic activity.11 An abrupt increase in the duration, intensity, or frequency of physical activity without adequate periods of rest may lead to excessive osteoclastic activity. The exact mechanism responsible for initiating stress fractures remains unclear. One theory holds that excessive forces are transmitted to

DIAGNOSIS

Early diagnosis, especially for femoral neck stress fractures, is critical for avoiding complications and returning the athlete to play as soon and as safely as possible. The onset of pain is gradual over a period of days to several weeks. Symptoms are usually aggravated by exercise and relieved with rest. Localizing the point of maximal tenderness may be more difficult in the femur than other lower extremity bones because of the large soft-tissue envelope. Stressing the femur via gentle

TREATMENT

The treatment of stress fractures depends on the underlying causes responsible for initiating the injury. Extrinsic factors, such as the training regimen, as well as intrinsic conditions, such as nutritional, hormonal, and medical abnormalities, need to be assessed. Training errors are the most frequent cause of stress fractures. These injuries can be appropriately treated by rest followed by a gradual resumption to activity. Medical evaluation is considered for any patient with increased risk

FEMORAL NECK STRESS FRACTURES

In a retrospective review of 320 athletes with stress fractures confirmed by bone scan, Matheson14 found the femur (7.2%) to be the fourth most common site of injury. Only those of the tibia (49%), tarsals (25.3%), and metatarsals (8.8%) were more prevalent in the athletic population. More recently, Johnson et al10 prospectively followed 914 athletes from 20 collegiate varsity teams. They reported 7 of 34 stress fractures (20.6%) to occur in the femoral shaft. Stress fractures of the femur have

FEMORAL CONDYLE STRESS FRACTURES

There are few published case reports of femoral condylar stress fractures.12, 15, 18 Despite the apparent rarity of this injury, the incidence may actually be underestimated. Stress fractures may be overlooked in favor of other soft-tissue diagnoses around the knee or avascular necrosis of the femoral condyles. Abnormal bone scans of the knee are often nonspecific, with a long differential including injuries to the growth plate or ligaments, osteochondritis dissecans, or osteonecrosis. MR

SUMMARY

Stress fractures are common overuse injuries attributed to the repetitive trauma associated with vigorous weightbearing activities. A high index of suspicion is necessary to diagnose stress fractures of the femur because the symptoms may be vague. The precipitating factors, whether related to training errors or medical conditions, should be thoroughly evaluated. Early diagnosis of distraction femoral neck stress fractures is critical to avoid serious complications. Femoral shaft stress

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Address reprint requests to Kevin P. Speer, MD, Department of Orthopedics, Sports Medicine Section, Duke University Medical Center, Durham, NC 27710

*

Department of Sports Medicine, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina

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