Rev. bras. ortop. vol.51 número6

r e v b r a s o r t o p . 2016;51(6):735–738

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

report

Bilateral

stress

fracture

of

femoral

neck

in

non-athlete

–

case

report

夽

Ubiratan

Stefani

de

Oliveira

_,

_Pedro

_José

_Labronici

,

André

João

Neto

,

Alexandre

Yukio

Nishimi

_,

_Robinson

_Esteves

_Santos

_Pires

_,

Luiz

Henrique

Penteado

Silva

a_{UniversidadeFederaldeSãoPaulo,DepartamentodeOrtopediaeTraumatologia,SãoPaulo,SP,Brazil}

b_{UniversidadeFederalFluminense,Niterói,RJ,Brazil}

c_{HospitalSantaTeresa,Servic¸odeOrtopediaeTraumatologia,Petrópolis,RJ,Brazil}

d_{UniversidadeFederaldeMinasGerais,BeloHorizonte,MG,Brazil}

e_{HospitaldoTraumaeHospitalEscolaSãoVicentePaula,PassoFundo,RS,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received17February2016 Accepted25February2016 Availableonline2November2016

Keywords: Fracturesbone Fracturesstress Femoralneckfractures Hippain

a

b

s

t

r

a

c

t

Bilateralstressfractureoffemoralneckinhealthyyoungpatientsisanextremelyrareentity, whosediagnosticandtreatmentrepresentamajorchallenge.Patientswithhistoryofhip pain,evennon-athletesormilitaryrecruits,shouldbeanalyzedtoachieveanearlydiagnosis andpreventpossiblecomplicationsfromthesurgicaltreatment.Thisreportdescribesa 43-year-oldmalepatient,non-athlete,withoutpreviousdiseases,whodevelopedbilateral stressfracture offemoralneckwithoutdisplacement.Hehadalatediagnosis;bilateral osteosynthesiswasmadeusingcannulatedscrews.Althoughthediagnosiswasdelayedin thiscase,thestudyhighlightstheimportanceofthediagnosisofstressfracture,regardless oftheactivitylevelofthepatients,forthesuccessofthetreatment.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Fratura

de

estresse

bilateral

do

colo

do

fêmur

em

não

atleta

–

relato

de

caso

Palavras-chave: Fraturasósseas Fraturasdeestresse Fraturasdocolofemoral Dornoquadril

r

e

s

u

m

o

Afraturadeestressebilateraldocolodofêmurempacientesadultossadioséuma enti-dadeextremamenterara,cujodiagnósticoetratamentorepresentamumgrandedesafio. Pacientescomhistóriadedornoquadril,mesmosenãoforematletasoumilitares,devemser analisadosparaseobterumdiagnósticoprecoceeprevenirpossíveiscomplicac¸ões prove-nientesdotratamentocirúrgico.Esterelatodescreveumpacientede43anos,nãoatleta,

夽

StudyconductedattheServiceofOrthopedyandTraumatology,HospitalSantaTeresa,Petrópolis,RJ,Brazil. ∗ _{Correspondingauthor.}

E-mail:[email protected](P.J.Labronici).

http://dx.doi.org/10.1016/j.rboe.2016.10.013

736

dogêneromasculino,semdoenc¸asprévias,quedesenvolveufraturadeestressedocolodo fêmurbilateralsemdesvio,diagnosticadoetratadotardiamentecomosteossíntesebilateral comparafusoscanulados.Apesardeodiagnósticotersidotardionessecaso,enfatiza-sea importânciadeseobterdiagnósticodefraturadeestresse,independentementedonívelde atividadedospacientes,paraosucessodotratamento.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Femoral neck stress fracture is an uncommon injury, and bilateralfractures areevenrarer.Thislocationcorresponds to5%ofallstressfractures,andare morecommonamong athletes (11%),militarypersonnel, the elderly, and individ-ualswithmetabolicdisorders,beingrarelyfoundinhealthy individuals.1,2

Thehomeostasisofbonetissuerequirescontinuous syn-thesis and absorption of bone components. Under normal conditions, there is a balance between osteoblastic recon-structionandosteoclasticresorption.3–5_{Osteoclasticactivity}

reachesapeakatthreeweeksafterthebeginningofthe repet-itivestress onthebone.3,6,7 _{Theaccumulationofabnormal}

mechanicalloadonagivenareaofthebonemayalterthe equilibriuminfavorofcatabolicosteoclastactivityand patho-logicallyincreaseboneresorption,producingmicrofractures inthebone.4,8

Etiologically, stress fractures can be divided into two types:(1)fatigue,whichissecondarytoanabnormalstress appliedon abone withnormal structureand elasticity9–11

(in the femoral neckthese fractures are often observed in military personnel and long-distance runners)12,13_{; (2) by}

the impairment of normal muscular force applied to the bone with poor structure and elasticity9,10,13 _{(occurs more}

frequently in older patients and is often associated with postmenopausalosteoporosisorothertypesofosteoporosis causedbyrheumatoidosteoporosis,diabetesmellitus,oruse ofcorticosteroids).9,10,14,15

Thisreportpresentsararecaseofbilateralstressfracture ofthefemoralneckinayoung,healthy,non-athletepatient.

Case

report

Malepatient,43,electrician,non-athlete,smoker,withno his-toryofmetabolicdisease,diabetes,impairedrenalfunction, oruseofcorticosteroids.Hereportedpaininbothhipsfora yearwheninprofessionalactivity,whichreducedatrest. Dur-ingthisperiod,hewasseeninvariousoutpatientclinicsand diagnosedwithtendinitisorpainduetooverloadofthehip joint,andwastreatedwithnon-steroidalanti-inflammatory drugs.Physical examinationrevealeddiscrete limping with painfulfacies,functionalimpairment,especiallyininternal rotation.Radiographicexaminationshowedabilateralcoxa vara withcorticalinterruptionand asclerotic area inboth femoralnecks(Fig.1).CTscanconfirmedthediagnosisand narrowfemoralneckswereobserved(Fig.2).Asthediagnosis

Fig.1–Panoramicanteroposteriorradiographofthepelvis disclosingbilateralcorticalinterruptionofthefemoralneck.

Fig.2–CTscanimageinaxialsectionofthefemoralneck regionofbothhips,showinganarrowandscleroticfemoral neck.

hadalreadybeendeterminedbyradiography,further exami-nations,suchasmagneticresonanceimagining(MRI)orbone scan,werenotnecessary.Thetreatmentwasfixationwithtwo 7-mmcannulatedscrews,asthefemoralneckwastoonarrow fortheplacementofthreescrewsoraslidinghipscrew(Fig.3). Asfixationwasperformedinbothhips,thepatientwas ori-ented tonotbearweightforsixweeks;thereafter, assisted loadingwithcrutcheswasauthorized.

Discussion

An epidemiological review revealed numerous risk factors for the development of stress fractures, including female gender, age, low bonedensity and bonestrength, low aer-obic conditioning,lowlevel ofphysicalactivityinthe past, smoking, and excessive running.16 _{Apulia et al.}17 _{found a}

rev bras ortop.2016;51(6):735–738

737

Fig.3–Panoramicanteroposteriorandlateralradiographsofthehipsshowingthefixationofbothfemoralneckswithtwo cannulatedscrews.

andstressfractureinmilitarypersonnel.Thesefracturesare alsofoundinpatientswithanabnormalfemoralanatomy, renalosteodystrophy,useofcorticosteroids,amenorrhea,and osteomalacia.18–24 _{Most reports of bilateral stress fracture}

arerelatedtoboneinsuficiencyandareobservedinelderly patients.Therefore,theauthorsbelievethatthepresentcase istrulyrare,asitoccurredinayoungadultwithnoevidenceof previousillnessormetabolicabnormalitythatcouldexplicate thefracture.

Naiketal.25_{haveshownthatrepetitiveactivitycould}

pro-duceanabnormalstressinbothhips.Thus,abilateralfemoral neckstressfracturecouldoccurinnon-athletepatients with-outbonechanges.Someauthorsbelievethatrepetitiveloadon thehipabductormusclesmayleadtomusclefatigueandloss oftheshockabsorptioncapacity.Musclefatigueaffectsthe positionofthebody’scenterofmass,andaltersthepattern ofstressandstrainonthefemoralneck.Clinicaland biome-chanicalstudieshavesuggestedthat,duetomusclefatigue, patientsdevelopacompensatorygaitthatmodifiestheforces actingon the hip, thus precipitatinga femoralneckstress fracture.26,27

Thecomplaintsincludegroin,thigh,orkneepainreducing atrestwhichmayrepresentadifficultdiagnosisduetothe vaguepresentationofsymptoms.2,28_{Thus,thesepatientsare}

oftentreatedformusclestrain,tendinitis,orearlyonsethip osteoarthrosis.29 _{Pihlajamäkietal.}30 _{notedthatthese}

com-plaintsshouldraiseahighdegreeofsuspicionforfemoralneck stressfracture inhealthy,young, male patientswho report paininthegroin and/orhipduringphysicalactivities.Itis alsoimportanttonotethatstressfractures,although symp-tomatic,are notincapacitatingunlesstheybecomeacutely displacedand/ormodifythehipjoint.25

Approximately75%offemoralneckstressfracturesmay bemisdiagnosedorundiagnosedonphysicalexamination.31

Whenbothsidesareinvolved,thepercentageofmisdiagnoses increasesevenfurther,astheyareoftenundisplaced.32

Clini-calexaminationisalsonon-specific;theremaybepainathip rotation,especiallywithlimitationandpainduringinternal rotation.

Attheonsetofsymptoms,radiographicexaminationmay benormal.Usually,radiographsdemonstratebonechanges two or three weeks after the onset of symptoms; these

alterations are diagnosedin less than 10–29% ofcases18,24

Duringradiographicexamination,itisimportanttokeepthe lowerlimbininternalrotation,sothattheentirelengthofthe femoralneckisbettershown.CTscanmayhelpdiagnosing, butMRIandbonescanareconsideredtobethemostsuitable exams forearlydiagnosis.Bonescanwithtechnetium-99m (99m_{Tc) is moresensitive in bone remodeling areas, but it}

lacksspecificityduetosimilarfindingsincasesofinfection, osteonecrosis,andtumor.MRIisconsideredtobe100% sen-sitive,specificandmoreaccurateforearlydiagnosisandfor differentiationwithtumorandinfection.19,23,24,33_Theauthors

agreewith Naiket al.25_{: whenthe fractures are evidentin}

theinitialradiograph,thereisnoneedforadditionalteststo confirmthediagnosis.Inthepresentcase,CTscanhelpednot onlyindiagnosis,butalsoevidencedaverynarrowfemoral neckbilaterally,whichhelpeddefinethesurgicaltechnique tobeused.

Treatmentoffemoralneckstressfracturesisstillagreat challengeforsurgeons.Uponradiographicexamination,two typesoffracturecanbeidentified:tensionandcompression. Themostconcerningarethosecausedbytension,astheymay displaceand,ifundiagnosed,causelateosteonecrosisofthe femoralhead.34 _{In youngandactiveindividuals with}

bilat-eralstressfractureofthefemoralneck,eveninnon-displaced fractures, prolonged bed rest is not recommended or reli-able.Osteosynthesisandearlyreferralforphysicalactivityare needed.However,complicationssuchasavascularnecrosis, re-fracture,varuscollapse,andnonunionhavebeenreported afterstabilizationwithmultiplescrewsorslidinghipscrew.18

Inthiscasereport,thepatientwasyoung,active,andthe frac-tureshowednodisplacement.Twocannulatedscrewswere indicatedforfixationofthefracture.Thisindicationwasmade aftersurgicalplanning,throughtheanalysisoftheCT,which indicatedthatthe femoralneckwastoonarrow.Therefore, the possibilityofstabilizationwithasliding hipscrewwas discarded,andtheauthorsdecidedtousethreecannulated screws.

738

emphasizetheimportanceofobtainingthediagnosisofstress fractureforsuccessfultreatment,regardlessofthepatient’s levelofactivity.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1. FullertonLRJr,SnowdyHA.Femoralneckstressfractures.Am JSportsMed.1988;16(4):365–77.

2. LassusJ,TulikouraI,KonttinenYT,SaloJ,SantavirtaS.Bone stressinjuriesofthelowerextremity:areview.ActaOrthop Scand.2002;73(3):359–68.

3. KhadabadiNA,PatilKS.Simultaneousbilateralfemoralneck stressfractureinayoungstonemason.CaseRepOrthop. 2015;2015:306246.

4. ChamayA,TschantzP.Mechanicalinfluencesinbone remodeling.ExperimentalresearchonWolff’slaw.JBiomech. 1972;5(2):173–80.

5. SterlingJC,EdelsteinDW,CalvoRD,WebbR2nd.Stress fracturesintheathlete.Diagnosisandmanagement.Sports Med.1992;14(5):336–46.

6. JonesBH,HarrisJM,VinhTN,RubinC.Exercise-inducedstress fracturesandstressreactionsofbone:epidemiology,etiology, andclassification.ExercSportSciRev.1989;17:379–422.

7. SallisRE,JonesK.Stressfracturesinathletes.Howtospotthis underdiagnosedinjury.PostgradMed.1991;89(6):185–8,191–2.

8. WerntzJR,LaneJM.Thebiologyofpathologicfracturerepair. In:LaneJM,HealeyJH,editors.Diagnosisandmanagementof pathologicfractures.NewYork:Raven;1993.p.1–11.

9. DaffnerRH,PavlovH.Stressfractures:currentconcepts.AmJ Roentgenol.1992;159(2):245–52.

10.RomaniWA,GieckJH,PerrinDH,SalibaEN,KahlerDM. Mechanismsandmanagementofstressfracturesin physicallyactivepersons.JAthlTrain.2002;37(3):306–14.

11.SimpsonPJ,LucchesiBR.Freeradicalsandmyocardial ischemiaandreperfusioninjury.JLabClinMed. 1987;110(1):13–30.

12.PihlajamäkiHK,RuoholaJP,WeckströmM,KiuruMJ,VisuriTI. Long-termoutcomeofundisplacedfatiguefracturesofthe femoralneckinyoungmaleadults.JBoneJointSurgBr. 2006;88(12):1574–9.

13.TalbotJC,CoxG,TownendM,LanghamM,ParkerPJ.Femoral neckstressfracturesinmilitarypersonnel–acaseseries.JR ArmyMedCorps.2008;154(1):47–50.

14.UmansH,PavlovH.Stressfracturesofthelowerextremities. SeminRoentgenol.1994;29(2):176–93.

15.KatholMH,el-KhouryGY,MooreTE,MarshJL.Calcaneal insufficiencyavulsionfracturesinpatientswithdiabetes mellitus.Radiology.1991;180(3):725–9.

16.JonesBH,ThackerSB,GilchristJ,KimseyCDJr,SosinDM. Preventionoflowerextremitystressfracturesinathletesand

soldiers:asystematicreview.EpidemiolRev. 2002;24(2):228–47.

17.PouillesJM,BernardJ,TremollièresF,LouvetJP,RibotC. Femoralbonedensityinyoungmaleadultswithstress fractures.Bone.1989;10(2):105–8.

18.DiwanjiSR,KongIK,ChoSG,SeonJK,YoonTR.Displaced stressfractureofthefemoralnecktreatedbyvalgus subtrochantericosteotomy:2casestudies.AmJSportsMed. 2007;35(9):1567–70.

19.GurdeziS,TrehanRK,RickmanM.Bilateralundisplaced insufficiencyneckoffemurfracturesassociatedwith short-termsteroiduse:acasereport.JMedCaseRep. 2008;2:79.

20.JohanssonC,EkenmanI,TörnkvistH,ErikssonE.Stress fracturesofthefemoralneckinathletes.Theconsequenceof adelayindiagnosis.AmJSportsMed.1990;18(5):524–8.

21.KarapinarH,OzdemirM,AkyolS,UlküO.Spontaneous bilateralfemoralneckfracturesinayoungadultwithchronic renalfailure.ActaOrthopBelg.2003;69(1):82–5.

22.ChadhaM,BalainB,MainiL,DhalA.Spontaneousbilateral displacedfemoralneckfracturesinnutritionalosteomalacia –acasereport.ActaOrthopScand.2001;72(1):94–6.

23.HaddadFS,MohannaPN,GoddardNJ.Bilateralfemoralneck stressfracturesfollowingsteroidtreatment.Injury.

1997;28(9–10):671–3.

24.IchikawaJ,AmanoR,HaroH,SatoE,KoyamaK,HamadaY. Fatiguefractureofthebilateralfemoralneckintheelderly. Orthopedics.2008;31(11):1141.

25.NaikMA,SujirP,TripathySK,VijayanS,HameedS,RaoSK. Bilateralstressfracturesoffemoralneckinnon-athletes:a reportoffourcases.ChinJTraumatol.2013;16(2):113–7.

26.MarkeyKL.Stressfractures.ClinSportsMed.1987;6(2):405–25.

27.DevasMB.Stressfracturesofthefemoralneck.JBoneJoint SurgBr.1965;47(4):728–38.

28.NaranjeS,SezoN,TrikhaV,KancherlaR,RijalL,JhaR. Simultaneousbilateralfemoralneckstressfracturesina youngmilitarycadet:ararecasereport.EurJOrthopSurg Traumatol.2012;22Suppl.1:103–6.

29.EgolKA,KovalKJ,KummerF,FrankelVH.Stressfracturesof thefemoralneck.ClinOrthopRelatRes.1998;(348): 72–8.

30.PihlajamäkiHK,RuoholaJP,KiuruMJ,VisuriTI.Displaced femoralneckfatiguefracturesinmilitaryrecruits.JBoneJoint SurgAm.2006;88(9):1989–97.

31.ProvencherMT,BaldwinAJ,GormanJD,GouldMT,ShinAY. Atypicaltensile-sidedfemoralneckstressfractures:thevalue ofmagneticresonanceimaging.AmJSportsMed.

2004;32(6):1528–34.

32.WrightRC,SalzmanGA,YacoubianSV,YacoubianSV. Bilateralfemoralneckstressfracturesinafireacademy student.Orthopedics.2010;33(10):767.

33.BailieDS,LamprechtDE.Bilateralfemoralneckstress fracturesinanadolescentmalerunner.Acasereport.AmJ SportsMed.2001;29(6):811–3.