Injury Clinic
Sports Medicine 9 (3): 191· 197. 1990 01 11.1641/90/0003·0191/$03.00/0 © ADIS Press Limited All rights reserved. SPORT2258
Femoral Neck Stress Fractures LeRoy R. Fullerton Jr Department of Surgery, Section of Orthopedics, Medical College of Georgia, Augusta, Georgia, USA
Contents
Summary .. ........... ...................................... ................ .. .............................................................. I . Aetiology and Bone Response ........... .................................................................................. 2. Diagnosis ....................................................................................................... ......... ............... 3. Radiography ......................................... ...................................... .......... .. ................ ............... 4. Classification ........................... .................................................................. ................... ......... 5. Treatment ................................... ........................................................................................... 6. Prognosis ........................... .................................................................................................... 7. Conclusions ............................................................................... ............................................
Summary
Femoral neck stress fractures are unusual but not rare athletic injuries. In one large series they accounted for 5% of all stress fractures. Early recognition of the signs and symptoms of this injury is important, as objective findings are often delayed. The po· tential problems from this fracture are serious. The aetiology includes repeated force above a certain load without internal bone response time. Loss of shock absorption due to muscle fatigue and limitation of ankle motion by boots or splints may also playa role. The diagnosis is based on the finding of groin pain and radiographic testing, which often requires plain films and bone scintigraphy. Regular radIographic findings present in stages progressing from a normal film through sclerosis to a disruption of the cortex and displacement. Bone scintigraphy may be positive 2 or more weeks before plain film changes are present. Classification schemes follow the radiographic changes. A c1assifi· cation system and treatment plan may be based on 3 categories of these fractures compression side, tension side and displaced femoral neck fracture. Treatment ranges from rest with early symptoms to surgical stabilisation for any widening of cortical cracks and/or displaced fractures. Prompt diagnosis and carefully supervised treatment is the key to preventing displacement. Prolonged disability secondary to pain, nonunion or avascular necrosis is associated with displacement of the femoral neck stress fracture.
It has become commonplace for athletes to develop one or more injuries that can be related to overuse in training. Of the common athletic training problems, stress fractures are often one of the easiest to diagnose, if there are radiographic changes
192 193 193 193 194 194 196 196
such as periosteal reaction or fracture. In the specific case of the femoral neck, there are important factors to be considered early in the course of the injury, even before radiographic response. The purpose of this paper is to discuss the natural his-
Femoral Neck Stress Fractures
tory of femoral neck stress fractures, to discuss the causes and to present a treatment plan. Series of stress fractures of the femoral neck were first documented in the I 960s. Ernst (1964) presented 13 cases. His report was followed by those of Devas (1965) [25 cases] and Blickenstaff & Morris (1966) [36 cases]. Since then there have been many reports of smaller numbers of patients that reinforce these early studies. In a study conducted at Fort Benning, Georgia, in 1983, the largest number of patients who developed femoral neck stress fractures were studied prospectively (Fullerton & Snowdy 1988). The results of that study, coupled with the earlier retrospective studies noted above, are used to update what is known concerning the aetiology, classification, complications and treatment of this injury.
1. Aetiology and Bone Response 'Stress is produced in a bone whenever bone is subject to a loading force. As a result of that stress, the bone will strain or change its dimensions. At low levels of stress, the bone will simply elastically deform, and upon removal of the loading force, will rebound to its original dimensions without having sustained any permanent damage. However, when stress above a certain critical limit is induced, the bone will be damaged in such a way that if it is repeatedly loaded to the same stress level, it will eventually fracture. As the loading force is increased progressively, fewer cycles of loading are required to produce a fracture' (Morris & Blickenstaff 1967). Combining these concepts with the frequent 2week delay in roentgenographic changes after onset of symptoms, the conclusion that stress can cause bone damage can be inferred. The osteoclastic resorption of this injured bone tissue is the physiological response to the injury. This is followed by osteoblastic deposition of new bone. As mineralisation of this new bone takes place, the repair becomes apparent on roentgenograms. In addition, periosteal new bone is often noted at the same time. It is not clear what causes the specific site of the femoral neck to develop a stress injury. One likely
193
factor is the loss of the normal shock absorbent effect of muscles as they become fatigued (Fullerton & Snowdy 1988; Scully & Besterman 1979). In addition, high stress repetition is a common finding in the history of this injury. Unfortunately, laboratory tests of the blood and machine testing of the cadaver femoral neck have not yet yielded more information on the causes of this injury (Belding 1980; Blickenstaff & Morris 1966; Ernst 1964; Lombardo & Benson 1982).
2. Diagnosis The usual history of a femoral neck stress fracture is that of the onset of progressive hip pain, sometimes beginning as early as 2 weeks after initiating or changing a conditioning programme. In the Fort Benning series, 40% ofthe patient's symptoms began during athletic activity between weeks 6 and 8 of training (Fullerton & Snowdy 1988). This training involved marching and running. In 87% of the patients in that study, the earliest and most frequent symptom was anterior groin (inguinal) pain. Night pain was reported in 19%. Physical examination reveals pain at the extremes of gentle passive hip motion. This finding was present in 79% of the Fort Benning series (Fullerton & Snowdy 1988). Palpatation of the groin overlying the hip joint is also likely to reproduce the patients' symptoms while pain on heel percussion is not often found. (Fullerton & Snowdy 1988). Laboratory studies of alkaline phosphatase, calcium, phosphorus and the sedimentation rate have not proven helpful (Blickenstaff & Morris 1966; Ernst 1964; Lombardo & Benson 1982).
3. Radiography Initial evaluation of the athletic patient complaining of hip pain should include an anteroposterior and lateral hip radiography. Radiographs taken soon after symptoms begin have been reported to be positive in less than 20% of cases (Fullerton & Snowdy 1988). If treatment is begun early, plain films may never show signs of change (Greaney et a1. 1983; Meurman & Elfring 1980; Prather
Sports Medicine 9 (3) 1990
194
et al. 1977; Wilcox et al. 1979). Bone scintigraphy is the most sensitive diagnostic test. While negative bone scans have been reported in cases that later had radiographic evidence of stress fractures, most series indicate scintigraphy to be the ultimate diagnostic test (Milgrom et al. 1984). False positives have not been reported in this clinical setting (Fullerton & Snowby 1988). In most cases repeat radiographs will become positive in I to 2 weeks (Prather et al. 1977). Early bone scintigraphy is indicated when definitive
a
diagnosis is critical in terms of the athlete's sport, job or reliability.
4. Classification Currently there are 3 systems of classification offemoral neck stress fractures. Devas (1965, 1975) first described and later modified a biomechanical system. His two patterns were 'those that are basically distracted, or being pulled open, and those that are compressed' (Devas 1975). Blickenstaff and Morris (1966) presented a descriptive classification based on the amount of fracture displacement. Type I fractures had callus without a visible fracture. Type II had a nondisplaced crack in the calcar or across the neck. Type III fractures were completely displaced. During the Fort Benning series, which was the first prospective study, Fullerton and Snowdy (1988) found the 2 existing classifications were difficult to apply when the diagnosis was made with early radiographic changes or with only bone scan findings. A third system was developed that combined the biomechanical factors and degree of displacement. The categories of this system are tension-side, compression-side and displaced fractures. Both the tension and compression type fractures have been shown to demonstrate a spectrum of changes. The earliest stage is a normal radiograph with a positive bone scintigraphy (fig. I). The next stage is manifest by either endosteal or periosteal callus without a fracture (fig. 2a). A cortical crack without displacement follows (fig. 2b). The final stages are a widening of the cortical crack (fig. 2c) and then displacement (fig. 3).
5. Treatment
Fig. 1. (a) Positive bone scintigraphy in patient with a compression type femoral neck stress fracture with normal roentgenogram; (b) Normal radiograph with positive bone scan.
The philosophy of treatment is based on the natural history of these fractures. It is influenced by the potentially disastrous consequences of a completely displaced femoral neck stress fracture in the athlete. When there is clinical evidence of this injury with either a normal radiograph with positive scintigraphy (increased uptake in the femoral neck) or sclerosis only, the treatment is bed rest until con-
Femoral Neck Stress Fractures
195
stant hip pain resolves. This may take several days. The patient is then advanced from partial to full weightbearing on crutches as symptoms permit. Once the patient is free of pain with crutches he is allowed to progress to a cane and then to unprotected weightbearing. A progressive walking, then running, programme is prescribed and that patient is returned over several months to full activity.
Fig. 2. (a) Compression side femoral neck stress fracture with sclerosis; (b) Compression side femoral neck stress fracture with a non-displaced cortical crack; (c) Tension side femoral neck stress fracture with widening.
Fig. 3. (a) Displaced femoral neck stress fracture; (b) Fixation of a displaced femoral neck stress fracture.
196
If the patient presents with or develops an undisplaced cortical crack on either the tension or compression side of the femoral neck, the treatment is different. He is placed on immediate bed rest and serial radiographs are taken every 2 to 3 days for the first week or until rest pain is relieved. Operative treatment is indicated if there is any widening of the fracture, if both cortices develop a defect, if bed rest is not feasible, or if the patient is not reliable and cooperative. In any of these instances the fracture is stablised on a semiemergent basis using multiple pins. If there is no change in the serial radiographs, once he is pain free at rest, the patient is allowed to progress his activity as noted above (Devas 1965). In those fractures that present with any widening or with a defect in both cortices, immediate fixation is recommended. After radiographic fracture healing and resolution of hip pain with unsupported walking, consideration may be given to removing the fixation on the athlete. It is recommended that the patient's activities be restricted for at least 3 months after pin removal to allow fill-in of the pin tracts. During that period the patient may be allowed to progress to jogging, but he should not be involved in competitive running or sports. Once there is clinical and radiographic evidence that the postsurgical defects have healed, then the patient may resume a progressive, controlled training programme of gradual increases in activity, such as running, walking and jumping. Those athletes who present with a displaced femoral neck stress fracture are treated surgically. Closed reduction and internal fixation with either multiple pins or a compression screw with side plate should be used. After fracture healing, consideration of implant removal and a very gradual progression in athletic activity may be considered.
6. Prognosis There were no problems with prolonged pain or subsequent progression in patients treated non-operatively in the Fort Benning study (Fullerton & Snowdy 1988). Intermittent discomfort with activity for 6 months to a year can occur. It is not known
Sports Medicine 9 (3) 1990
if early operative treatment would shorten the symptomatic period. Progression after diagnosis and treatment is not common (Black 1974; Blickenstaff & Morris 1966; Fullerton & Snowdy 1988). Reports of displacement, however, should alert the physician to the potential problems. Avascular necrosis and nonunion are 2 disastrous problems that can occur (Kaltsas 1981). In those cases, prolonged impairment is likely.
7. Conclusions Hip pain in athletes at onset of training or near the time of a significant change in activities should be evaluated promptly. Clinical examination and radiographs are indicated. In the face of normal plain films, restricted activity is in order. If pain persists or if the training/job situation dictates, then early bone scintigraphy is appropriate. Once the diagnosis is made, then the appropriate treatment, either protected weightbearing or surgery, should be performed. A gradual return to full activity is likely, but prolonged discomfort during the recovery phase is not unusual. Early modification in the athlete's activity has the potential to allow resolution of symptoms with any radiographic changes (Greaney et al. 1983; Meurman & Elfring 1980; Prather et al. 1977; Wilcox et al. 1979).
Acknowledgement The author wishes to acknowledge the assistance and support of Ms Cissy Spence.
References Belding RH. Stress fractures of the femoral neck. Orthopaedic Transactions 4 (3): 377, 1980 Black J. failure of implants for internal hip fixation. Orthopaedic Clinics of North America 5 (4): 833-845, 1974 BlickenstafTLD, Morris JM. fatigue fracture of the femoral neck. Journal of Bone and Joint Surgery 48A: 1031-1047, 1966 Devas MB. Stress fractures of the femoral neck. Journal of Bone and Joint Surgery 47B: 728-738, 1965 Devas MB. Stress fractures, p. 113, Churchill Livingston, Edinburgh, 1975 Ernst J. Stress fracture of the neck of the femur. Journal of Trauma 4: 71-73, 1964 Fullerton LR, Snowdy HA. Femoral neck stress fractures. American Journal of Sports Medicine 16 (4): 365-377, 1988
Femoral Neck Stress Fractures
Greaney RB, Gerber FA, Laughlin RL, et al. Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology 146: 339-346, 1983 Kaltsas DS. Stress fractures of the femoral neck in young adults. Journal of Bone and Joint Surgery 63B: 33-37, 1981 Lombardo SJ, Benson D. Stress fractures of the femur in runners. American Journal of Sports Medicine 10: 219-227, 1982 Meurman KOA, Elfring S. Stress fractures in soldiers: a multifocal bone disorder. Radiology 134: 483-487, 1980 Milgrom C. Chisin R, Giladi M, et al. Negative bone scans in impending tibial stress fractures: a report of three cases. American Journal of Sports Medicine 12: 488-491,1984 Morris JM, Blickenstaff LD. Fatigue fractures: a clinical study, Charles C. Thomas, Springfield, IL, 1967
197
Prather JL, Nusynowitz ML, Snowdy HA, et al. Scintigraphic findings in stress fractures. Journal of Bone and Joint Surgery 59A: 869-874, 1977 Scully TJ, Besterman JB. Stress fracture - a preventable training injury. Monograph from Orthopaedic and Rehabilitation Department, William Beaumont Army Medical Center, EI Paso, 1979 Wilcox JR, Monrit AL, Green JP. Bone scanning in the evaluation of exercise-related stress injuries. Radiology 123: 699-703, 1979
Author's address: Dr LeRoy R. Fullerton Jr, 820 St. Sebastian Way, Suite 8-A, Augusta, GA 30910, USA.
Sports Medicine 9 (3): 191· 197. 1990 01 11.1641/90/0003·0191/$03.00/0 © ADIS Press Limited All rights reserved. SPORT2258
Femoral Neck Stress Fractures LeRoy R. Fullerton Jr Department of Surgery, Section of Orthopedics, Medical College of Georgia, Augusta, Georgia, USA
Contents
Summary .. ........... ...................................... ................ .. .............................................................. I . Aetiology and Bone Response ........... .................................................................................. 2. Diagnosis ....................................................................................................... ......... ............... 3. Radiography ......................................... ...................................... .......... .. ................ ............... 4. Classification ........................... .................................................................. ................... ......... 5. Treatment ................................... ........................................................................................... 6. Prognosis ........................... .................................................................................................... 7. Conclusions ............................................................................... ............................................
Summary
Femoral neck stress fractures are unusual but not rare athletic injuries. In one large series they accounted for 5% of all stress fractures. Early recognition of the signs and symptoms of this injury is important, as objective findings are often delayed. The po· tential problems from this fracture are serious. The aetiology includes repeated force above a certain load without internal bone response time. Loss of shock absorption due to muscle fatigue and limitation of ankle motion by boots or splints may also playa role. The diagnosis is based on the finding of groin pain and radiographic testing, which often requires plain films and bone scintigraphy. Regular radIographic findings present in stages progressing from a normal film through sclerosis to a disruption of the cortex and displacement. Bone scintigraphy may be positive 2 or more weeks before plain film changes are present. Classification schemes follow the radiographic changes. A c1assifi· cation system and treatment plan may be based on 3 categories of these fractures compression side, tension side and displaced femoral neck fracture. Treatment ranges from rest with early symptoms to surgical stabilisation for any widening of cortical cracks and/or displaced fractures. Prompt diagnosis and carefully supervised treatment is the key to preventing displacement. Prolonged disability secondary to pain, nonunion or avascular necrosis is associated with displacement of the femoral neck stress fracture.
It has become commonplace for athletes to develop one or more injuries that can be related to overuse in training. Of the common athletic training problems, stress fractures are often one of the easiest to diagnose, if there are radiographic changes
192 193 193 193 194 194 196 196
such as periosteal reaction or fracture. In the specific case of the femoral neck, there are important factors to be considered early in the course of the injury, even before radiographic response. The purpose of this paper is to discuss the natural his-
Femoral Neck Stress Fractures
tory of femoral neck stress fractures, to discuss the causes and to present a treatment plan. Series of stress fractures of the femoral neck were first documented in the I 960s. Ernst (1964) presented 13 cases. His report was followed by those of Devas (1965) [25 cases] and Blickenstaff & Morris (1966) [36 cases]. Since then there have been many reports of smaller numbers of patients that reinforce these early studies. In a study conducted at Fort Benning, Georgia, in 1983, the largest number of patients who developed femoral neck stress fractures were studied prospectively (Fullerton & Snowdy 1988). The results of that study, coupled with the earlier retrospective studies noted above, are used to update what is known concerning the aetiology, classification, complications and treatment of this injury.
1. Aetiology and Bone Response 'Stress is produced in a bone whenever bone is subject to a loading force. As a result of that stress, the bone will strain or change its dimensions. At low levels of stress, the bone will simply elastically deform, and upon removal of the loading force, will rebound to its original dimensions without having sustained any permanent damage. However, when stress above a certain critical limit is induced, the bone will be damaged in such a way that if it is repeatedly loaded to the same stress level, it will eventually fracture. As the loading force is increased progressively, fewer cycles of loading are required to produce a fracture' (Morris & Blickenstaff 1967). Combining these concepts with the frequent 2week delay in roentgenographic changes after onset of symptoms, the conclusion that stress can cause bone damage can be inferred. The osteoclastic resorption of this injured bone tissue is the physiological response to the injury. This is followed by osteoblastic deposition of new bone. As mineralisation of this new bone takes place, the repair becomes apparent on roentgenograms. In addition, periosteal new bone is often noted at the same time. It is not clear what causes the specific site of the femoral neck to develop a stress injury. One likely
193
factor is the loss of the normal shock absorbent effect of muscles as they become fatigued (Fullerton & Snowdy 1988; Scully & Besterman 1979). In addition, high stress repetition is a common finding in the history of this injury. Unfortunately, laboratory tests of the blood and machine testing of the cadaver femoral neck have not yet yielded more information on the causes of this injury (Belding 1980; Blickenstaff & Morris 1966; Ernst 1964; Lombardo & Benson 1982).
2. Diagnosis The usual history of a femoral neck stress fracture is that of the onset of progressive hip pain, sometimes beginning as early as 2 weeks after initiating or changing a conditioning programme. In the Fort Benning series, 40% ofthe patient's symptoms began during athletic activity between weeks 6 and 8 of training (Fullerton & Snowdy 1988). This training involved marching and running. In 87% of the patients in that study, the earliest and most frequent symptom was anterior groin (inguinal) pain. Night pain was reported in 19%. Physical examination reveals pain at the extremes of gentle passive hip motion. This finding was present in 79% of the Fort Benning series (Fullerton & Snowdy 1988). Palpatation of the groin overlying the hip joint is also likely to reproduce the patients' symptoms while pain on heel percussion is not often found. (Fullerton & Snowdy 1988). Laboratory studies of alkaline phosphatase, calcium, phosphorus and the sedimentation rate have not proven helpful (Blickenstaff & Morris 1966; Ernst 1964; Lombardo & Benson 1982).
3. Radiography Initial evaluation of the athletic patient complaining of hip pain should include an anteroposterior and lateral hip radiography. Radiographs taken soon after symptoms begin have been reported to be positive in less than 20% of cases (Fullerton & Snowdy 1988). If treatment is begun early, plain films may never show signs of change (Greaney et a1. 1983; Meurman & Elfring 1980; Prather
Sports Medicine 9 (3) 1990
194
et al. 1977; Wilcox et al. 1979). Bone scintigraphy is the most sensitive diagnostic test. While negative bone scans have been reported in cases that later had radiographic evidence of stress fractures, most series indicate scintigraphy to be the ultimate diagnostic test (Milgrom et al. 1984). False positives have not been reported in this clinical setting (Fullerton & Snowby 1988). In most cases repeat radiographs will become positive in I to 2 weeks (Prather et al. 1977). Early bone scintigraphy is indicated when definitive
a
diagnosis is critical in terms of the athlete's sport, job or reliability.
4. Classification Currently there are 3 systems of classification offemoral neck stress fractures. Devas (1965, 1975) first described and later modified a biomechanical system. His two patterns were 'those that are basically distracted, or being pulled open, and those that are compressed' (Devas 1975). Blickenstaff and Morris (1966) presented a descriptive classification based on the amount of fracture displacement. Type I fractures had callus without a visible fracture. Type II had a nondisplaced crack in the calcar or across the neck. Type III fractures were completely displaced. During the Fort Benning series, which was the first prospective study, Fullerton and Snowdy (1988) found the 2 existing classifications were difficult to apply when the diagnosis was made with early radiographic changes or with only bone scan findings. A third system was developed that combined the biomechanical factors and degree of displacement. The categories of this system are tension-side, compression-side and displaced fractures. Both the tension and compression type fractures have been shown to demonstrate a spectrum of changes. The earliest stage is a normal radiograph with a positive bone scintigraphy (fig. I). The next stage is manifest by either endosteal or periosteal callus without a fracture (fig. 2a). A cortical crack without displacement follows (fig. 2b). The final stages are a widening of the cortical crack (fig. 2c) and then displacement (fig. 3).
5. Treatment
Fig. 1. (a) Positive bone scintigraphy in patient with a compression type femoral neck stress fracture with normal roentgenogram; (b) Normal radiograph with positive bone scan.
The philosophy of treatment is based on the natural history of these fractures. It is influenced by the potentially disastrous consequences of a completely displaced femoral neck stress fracture in the athlete. When there is clinical evidence of this injury with either a normal radiograph with positive scintigraphy (increased uptake in the femoral neck) or sclerosis only, the treatment is bed rest until con-
Femoral Neck Stress Fractures
195
stant hip pain resolves. This may take several days. The patient is then advanced from partial to full weightbearing on crutches as symptoms permit. Once the patient is free of pain with crutches he is allowed to progress to a cane and then to unprotected weightbearing. A progressive walking, then running, programme is prescribed and that patient is returned over several months to full activity.
Fig. 2. (a) Compression side femoral neck stress fracture with sclerosis; (b) Compression side femoral neck stress fracture with a non-displaced cortical crack; (c) Tension side femoral neck stress fracture with widening.
Fig. 3. (a) Displaced femoral neck stress fracture; (b) Fixation of a displaced femoral neck stress fracture.
196
If the patient presents with or develops an undisplaced cortical crack on either the tension or compression side of the femoral neck, the treatment is different. He is placed on immediate bed rest and serial radiographs are taken every 2 to 3 days for the first week or until rest pain is relieved. Operative treatment is indicated if there is any widening of the fracture, if both cortices develop a defect, if bed rest is not feasible, or if the patient is not reliable and cooperative. In any of these instances the fracture is stablised on a semiemergent basis using multiple pins. If there is no change in the serial radiographs, once he is pain free at rest, the patient is allowed to progress his activity as noted above (Devas 1965). In those fractures that present with any widening or with a defect in both cortices, immediate fixation is recommended. After radiographic fracture healing and resolution of hip pain with unsupported walking, consideration may be given to removing the fixation on the athlete. It is recommended that the patient's activities be restricted for at least 3 months after pin removal to allow fill-in of the pin tracts. During that period the patient may be allowed to progress to jogging, but he should not be involved in competitive running or sports. Once there is clinical and radiographic evidence that the postsurgical defects have healed, then the patient may resume a progressive, controlled training programme of gradual increases in activity, such as running, walking and jumping. Those athletes who present with a displaced femoral neck stress fracture are treated surgically. Closed reduction and internal fixation with either multiple pins or a compression screw with side plate should be used. After fracture healing, consideration of implant removal and a very gradual progression in athletic activity may be considered.
6. Prognosis There were no problems with prolonged pain or subsequent progression in patients treated non-operatively in the Fort Benning study (Fullerton & Snowdy 1988). Intermittent discomfort with activity for 6 months to a year can occur. It is not known
Sports Medicine 9 (3) 1990
if early operative treatment would shorten the symptomatic period. Progression after diagnosis and treatment is not common (Black 1974; Blickenstaff & Morris 1966; Fullerton & Snowdy 1988). Reports of displacement, however, should alert the physician to the potential problems. Avascular necrosis and nonunion are 2 disastrous problems that can occur (Kaltsas 1981). In those cases, prolonged impairment is likely.
7. Conclusions Hip pain in athletes at onset of training or near the time of a significant change in activities should be evaluated promptly. Clinical examination and radiographs are indicated. In the face of normal plain films, restricted activity is in order. If pain persists or if the training/job situation dictates, then early bone scintigraphy is appropriate. Once the diagnosis is made, then the appropriate treatment, either protected weightbearing or surgery, should be performed. A gradual return to full activity is likely, but prolonged discomfort during the recovery phase is not unusual. Early modification in the athlete's activity has the potential to allow resolution of symptoms with any radiographic changes (Greaney et al. 1983; Meurman & Elfring 1980; Prather et al. 1977; Wilcox et al. 1979).
Acknowledgement The author wishes to acknowledge the assistance and support of Ms Cissy Spence.
References Belding RH. Stress fractures of the femoral neck. Orthopaedic Transactions 4 (3): 377, 1980 Black J. failure of implants for internal hip fixation. Orthopaedic Clinics of North America 5 (4): 833-845, 1974 BlickenstafTLD, Morris JM. fatigue fracture of the femoral neck. Journal of Bone and Joint Surgery 48A: 1031-1047, 1966 Devas MB. Stress fractures of the femoral neck. Journal of Bone and Joint Surgery 47B: 728-738, 1965 Devas MB. Stress fractures, p. 113, Churchill Livingston, Edinburgh, 1975 Ernst J. Stress fracture of the neck of the femur. Journal of Trauma 4: 71-73, 1964 Fullerton LR, Snowdy HA. Femoral neck stress fractures. American Journal of Sports Medicine 16 (4): 365-377, 1988
Femoral Neck Stress Fractures
Greaney RB, Gerber FA, Laughlin RL, et al. Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology 146: 339-346, 1983 Kaltsas DS. Stress fractures of the femoral neck in young adults. Journal of Bone and Joint Surgery 63B: 33-37, 1981 Lombardo SJ, Benson D. Stress fractures of the femur in runners. American Journal of Sports Medicine 10: 219-227, 1982 Meurman KOA, Elfring S. Stress fractures in soldiers: a multifocal bone disorder. Radiology 134: 483-487, 1980 Milgrom C. Chisin R, Giladi M, et al. Negative bone scans in impending tibial stress fractures: a report of three cases. American Journal of Sports Medicine 12: 488-491,1984 Morris JM, Blickenstaff LD. Fatigue fractures: a clinical study, Charles C. Thomas, Springfield, IL, 1967
197
Prather JL, Nusynowitz ML, Snowdy HA, et al. Scintigraphic findings in stress fractures. Journal of Bone and Joint Surgery 59A: 869-874, 1977 Scully TJ, Besterman JB. Stress fracture - a preventable training injury. Monograph from Orthopaedic and Rehabilitation Department, William Beaumont Army Medical Center, EI Paso, 1979 Wilcox JR, Monrit AL, Green JP. Bone scanning in the evaluation of exercise-related stress injuries. Radiology 123: 699-703, 1979
Author's address: Dr LeRoy R. Fullerton Jr, 820 St. Sebastian Way, Suite 8-A, Augusta, GA 30910, USA.
