A 24-year-old male presents with progressively worsening left groin pain for six weeks after he began training for a marathon. He states he had x-rays done by his PCP that were negative four weeks ago and was diagnosed with a groin strain. X-rays were obtained and featured to the right.
What is your diagnosis? What is the typical mechanism? What is your management in the Emergency Department? What is your disposition?
Figure 1: Case courtesy of Dr. Hein Els, Radiopaedia.org.
Femoral neck stress fracture (FNSF)
- Pearl: FNSF diagnosis is difficult because the physical exam is non-specific. Patients present with an antalgic gait, pain with end range of motion at the hip, pain with combined flexion, abduction and external rotation, and pain with hip log roll [2].
- Pearl: X-rays for FNSF usually are not positive early in the course and if missed can lead to complications such as complete fracture, displacement, non-union, and avascular necrosis. Keep a high clinical suspicion in a running athlete [3,4].
- Femoral neck stress fractures are usually a result of repetitive abductor muscle contraction [1].
- Onset is often insidious. Pain is worse with weight-bearing and activity and improves with cessation of activity. The injury often occurs secondary to a recent change in activity intensity or volume [1,2].
- Femoral neck stress fractures are uncommon injuries, but are prevalent among long-distance runners and military recruits.
- Obtain AP and oblique hip radiographs to start
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Pearl: There are two sites where the stress fracture can occur.
- Compression side (inferior femoral neck) which is seen in this case.
- The patient should be made non-weight bearing with crutches.
- Tension side (superior femoral neck). These fractures are less common but require surgical fixation [1,2].
- Orthopedics should be consulted in the emergency department to determine whether the patient should go for urgent internal fixation [1,2,3].
- Compression side (inferior femoral neck) which is seen in this case.
- Pearl: If the patient is non-weight bearing, consider a rapid MRI of the hip (see Figure 2). These scans with the appropriate technician can be performed in 5-10 minutes [5].
Figure 2: MRI of the left hip demonstrating a linear hypointense signal at the base of the femoral neck. Case courtesy of Dr. Hein Els, Radiopaedia.org
- Compression side FNSF: Discharge with follow-up with sports medicine or orthopedics in 1-3 days for further management.
- Tension side FNSF: Will be determined on a case-by-case basis – discuss with orthopedics if inpatient management is required.
References:
- Brukner P, Khan K. Brukner & Khans Clinical Sports Medicine. North Ryde, N.S.W.: McGraw-Hill Education (Australia); 2017
- Harrast MA, Finnoff JT. Sports Medicine: Study Guide and Review for Boards. New York, NY: Demos Medical Publishing; 2017
- Biz, C., Berizzi, A., Crimi, A., et al. Management and Treatment of Femoral Neck Stress Fractures in Recreational Runners: A Report of Four Cases and Review of the Literature. Acta Biomedica. 2017; 88(4): 96-106. PMID: 29083360
- Clough, T. Femoral Neck Stress Fracture: The Importance of Clinical Suspicion and Early Review. 2002; 36(4): 308-309. PMID: 12145125
- Lauren May MA, Chen DC, Liem Bui-Mansfield CT, Usa M, Seth O LD. Rapid Magnetic Resonance Imaging Evaluation of Femoral Neck Stress Fractures in a U.S. Active Duty Military Population. Mil Med. 1619;182. PMID: 28051983
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