Femoral stress fractures in adults
- Jonathan Jackson, MD
Jonathan Jackson, MD
- Assistant Professor of Family Medicine
- Uniformed Services University of the Health Sciences
- Section Editors
- Patrice Eiff, MD
Patrice Eiff, MD
- Section Editor — Adult Orthopedics; Sports-Related Injuries
- Professor of Family Medicine
- Oregon Health & Science University
- Chad A Asplund, MD, FACSM, MPH
Chad A Asplund, MD, FACSM, MPH
- Associate Professor of Health and Kinesiology
- Director of Athletic Medicine
- Head Team Physician
- Georgia Southern University
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
The femur, as the largest bone in the body, has dozens of muscle origins and insertions . As such, it is prone to stress injury at several locations. Stress injury (including stress reaction and stress fracture) denotes gradual structural compromise (from edema to frank cortical fracture) due to training overload. Stress fractures may be incomplete or complete, and either non-displaced or displaced. Femoral neck stress fractures are considered high-risk for complications, particularly displacement; whereas, femoral shaft stress fractures are low-risk.
This topic is focused on overuse stress injury of the femur in physically active individuals, and will discuss patterns of femoral stress fractures (both epidemiologic and patho-anatomic), examination findings, radiographic assessment, and treatment. Insufficiency fractures in older adult patients, acute traumatic femur fractures, and stress fractures generally are reviewed separately. (See "Hip fractures in adults" and "Midshaft femur fractures in adults" and "Overview of stress fractures".)
EPIDEMIOLOGY AND RISK FACTORS
Femoral stress fractures (FSF) are uncommon. In case series, they comprise between 1 and 25 percent of all stress fractures [2-5]. While the exact overall incidence is not known, the observational studies reporting a higher incidence likely include more athletes participating in distance running. While smaller series report that FSF are more common in military trainees than athletes (as a percentage of stress fractures) [6,7], studies with larger numbers show comparable rates in both groups (ranging from 1 to 7 percent of all stress fractures) [8,9]. In most studies, femoral neck injuries are more common than femoral shaft stress fractures [6-8], although this finding is not consistent [9,10].
Overuse FSF have been diagnosed in patients from age five  to physically active adults in their 50s and 60s [2,12]. The large majority of published studies involve athletes and military recruits in their late teens and early 20s , and most subjects are male.
FSF are most commonly associated with running [2,3,10]. A systematic review of the risks for femoral stress fractures identified two well-established factors: female gender and previous history of stress fracture . Female athletes and female military recruits are thought to be at higher risk for FSF due to lower body mass and lower bone mineral density than males. Those with amenorrhea or poor aerobic fitness prior to starting military training are at particular risk [15,16]. FSF also occur in those who are overweight with limited participation in sports . (See "Functional hypothalamic amenorrhea: Pathophysiology and clinical manifestations".)
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- EPIDEMIOLOGY AND RISK FACTORS
- CLINICAL ANATOMY
- MECHANISM OF INJURY
- CLINICAL PRESENTATION AND EXAMINATION
- Examination findings
- DIAGNOSTIC IMAGING
- DIFFERENTIAL DIAGNOSIS
- INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL
- Basic initial care
- Femoral neck stress fracture treatment
- - Tension (superolateral) side fracture
- - Compression (inferomedial) side fracture
- Femoral shaft stress fracture treatment
- Condylar and supracondylar femoral stress fracture
- Unproven therapies
- FOLLOW-UP CARE AND PREVENTION
- RETURN TO WORK AND SPORT
- SUMMARY AND RECOMMENDATIONS