Round # 18

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Diagnosis and Discussion

Correct Diagnosis: Bilateral Insufficiency Fractures of the Femoral Neck

Discussion:
Although osteoporosis and trauma-related fractures are common in elderly patients, insufficiency fractures, especially of the femoral neck are relatively uncommon. More commonly affected sites include the pelvic girdle, sacrum, and tibia. This type of fracture is caused by either increased tensile or compressive forces acting at the femoral neck, and can occur in areas of weak bone during periods of normal to increased daily activity. Compressive lesions are usually found on the inferomedial aspect of the femoral neck, are more commonly seen in younger athletic patients, and are usually amenable to non-surgical treatment. This is in contrast to tension-induced lesions which predominate in the elderly, which almost always require surgical stabilization. Common risk factors in the elderly include osteoporosis, rheumatoid arthritis, steroid treatment, and hyperparathyroidism.

The clinical signs of an insufficiency fracture often come on suddenly, and are exacerbated by weight-bearing. Diagnosis is made by plain radiography, with bone scintigraphy or MRI used if the index of suspicion is high and plain films are initially negative. Treatment of osteoporosis-induced insufficiency fractures of the femoral neck almost always requires operative stabilization due to the potential instability of this lesion. However, some authors have argued that fractures visible only by bone scan may initially be treated non-operatively with reduced weightbearing and close follow-up.

References:

1. Soubrier M, Dubost JJ, Boisgard S, Sauvezie B, Gaillard P, Michel JL, Ristori JM. Insufficiency fracture. A survey of 60 cases and review of the literature. Joint Bone Spine. 2003;70(3):209-18.
2. Pearce DH, White LM, Bell RS. Musculoskeletal images. Bilateral insufficiency fracture of the femoral neck. Can J Surg 44(1):11-2, 2001.
3. Egol KA, Koval KJ, Kummer F, Frankel VH. Stress fractures of the femoral neck. Clin Orthop 348:72-8, 1998.

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