Femoral neck stress fractures


Fem neck stressFemoral neck stress fracture MRI





Running athletes

Female triad - anorexia /  amenorrhea / osteoporosis

Osteomalacia / decreased bone mineral density

Coxa vara / coxa valgus



Femoral stress coxa vara

Femoral neck fracture on right in patient with coxa vara


History / Examination


No trauma episode


Groin pain

- worse with activity

- improves with rest


Groin pain with examination




Compression / inferior neck

- surgery for > 50% fracture line or hip effusion


Tension / superior neck

- surgery for any fracture line



- no fracture line

- < 50% fracture line

- > 50% fracture line

- Complete fracture without displacement

- Complete displaced fractures


Stress # 1Stress # 2




Can be normal

Sclerosis / fracture line


Hip stressFem neck stress

Increased sclerosis at inferior neck              Xray demonstrating incomplete fracture of the superior neck




Fracture line


HIp stress CTHip stress CT

CT demonstrating incomplete fracture at inferior neck


Superior hip stress fractureHip stress fracture CT

CT demonstrate likely complete fracture, with some displacement




Edema / fracture line / hip effusion


Stress mRIMRI hip stress

MRI demonstrating edema likely across entire neck


Hip Stress FractureHIp Stress FractureHip Stress Fracture 3

MRI demonstrates complete fracture


Femoral neck stress fracture MRIMRI completeHip scress #






Obtain healing

Prevent progression to complete fracture / displacement


Non operative



- Tension side edema with no fracture line

- Compression side < 50%



- 6 weeks non weight bearing

- screen for osteomalacia / BMD

- Vitamin D / Calcium

- minimize activity for 4 - 6 months

- ensure healing on CT / MRI




Steele et al JBJS Am 2018

- 257 femoral neck stress changes or incomplete fractures treated nonoperatively

- stress changes: no progression treated nonoperatively

- < 50% fracture lines: 27/103 (26%) progression of fracture lines and required surgery

- hip effusion on MRI a risk factor for fracture progression







- involving > 50% neck diameter

- involving < 50% neck diameter with hip effusion


Tension side

- fracture line evident





- cannulated screws

- DHS + derotation screw

- +/- minus open reduction


Stress ORIF 1Stress ORIF




Griffis et al Adv Surg Orthop Adv 2018

- 53 military members with incomplete femoral stress fractures

- all treated with surgery

- no progression of fractures to complete

- return to duty 67%

- 17% return in Marine Corp

- 82% return in general Navy


Lee et al Arch Orthop Trauma Surg 2003

- 42 military members with displaced femoral neck fractures

- open reduction and fixation

- 28% developed AVN

- associated with delay to treatment and postoperative varus malunion