High Yield Overview

FEMORAL NECK STRESS FRACTURES

Tension vs Compression | MRI Gold Standard | Surgical Emergency if Tension Side

TensionSuperior cortex = surgical emergency

CompressionInferior cortex = conservative possible

5%All stress fractures

F greater than MFemale athlete triad

FEMORAL NECK STRESS FRACTURE TYPES

Tension (Superior)

PatternHigh risk - can displace

TreatmentSURGICAL - prophylactic fixation

Compression (Inferior)

PatternLower risk

TreatmentConservative (non-weight bearing)

Displaced

PatternComplete fracture

TreatmentUrgent surgical fixation

Critical Must-Knows

Tension side (superior cortex) requires prophylactic surgical fixation - high displacement risk
Compression side (inferior cortex) can be managed conservatively with non-weight bearing
MRI is gold standard - X-rays often negative initially
Female athlete triad - amenorrhea, low energy availability, low BMD
Military recruits and runners are highest risk populations

Examiner's Pearls

"
Groin pain in young athlete/military recruit = stress fracture until proven otherwise
"
X-rays often negative for 2-4 weeks - MRI for early diagnosis
"
Superior cortex involvement = surgical emergency (high displacement risk)
"
Return to sport requires MRI evidence of healing

Clinical Imaging

Imaging Gallery

3-panel X-ray vs MRI comparison showing superiority of MRI for early detectionCredit: Unknown via Open-i (NIH) (CC-BY 4.0)

2-panel: tension-side fracture pre-op and DHS fixation post-opCredit: Unknown via Open-i (NIH) (CC-BY 4.0)

2-panel coronal MRI showing bone marrow edema at femoral neck with arrowsCredit: Unknown via MedPix/Wikimedia Commons (Public Domain)

2-panel X-ray and bone scan showing stress fracture with increased uptakeCredit: Unknown via MedPix/Wikimedia Commons (Public Domain)

Critical Femoral Neck Stress Fracture Exam Points

Tension vs Compression

This is THE exam question. Tension side (superior cortex) = surgical fixation required. Compression side (inferior cortex) = conservative management possible. Get this wrong and you fail.

MRI is Gold Standard

X-rays are often negative for 2-4 weeks. MRI shows bone marrow edema early. Always order MRI if clinical suspicion high and X-rays negative.

Female Athlete Triad

Low energy availability, menstrual dysfunction, low BMD. Must screen female athletes with stress fractures. Endocrine referral if triad suspected.

High-Risk Location

Femoral neck is a high-risk stress fracture location due to displacement potential and AVN risk. More aggressive management than tibial stress fractures.

Femoral Neck Stress Fracture Management Algorithm

Fracture Type	Location	Treatment
Tension-side stress fracture	Superior cortex involvement	SURGICAL - prophylactic screw fixation
Compression-side stress fracture	Inferior cortex only	Non-weight bearing 6-8 weeks, serial imaging
Displaced fracture	Complete with displacement	Urgent surgical fixation (cannulated screws or DHS)
Compression side - not healing	Progressive symptoms at 6 weeks	Convert to surgical fixation
Bilateral stress reaction	Both hips affected	Address underlying cause, extended rest

Mnemonic

TENSION - Superior Side Management

Top of femoral neck (superior)

Tension forces on superior cortex

Emergency surgical referral

High displacement risk

Non-weight bearing while awaiting surgery

Prevent displacement

Screw fixation (prophylactic)

Cannulated screws

Imaging with MRI confirms

Gold standard diagnosis

Osteonecrosis risk if displaced

AVN complication

No delay in treatment

Urgent surgical management

Memory Hook:TENSION side = Top side = T for TROUBLE - needs surgery!

Mnemonic

COMPRESSION - Inferior Side Management

Conservative management possible

Non-operative option

Off weight bearing 6-8 weeks

Protected mobilization

MRI for monitoring healing

Serial imaging

Progressive return to activity

Gradual loading

Risk stratify for female triad

Address underlying cause

Evaluate bone health

DEXA, vitamin D

Surgery if fails or progresses

Conversion to surgery

Serial clinical and imaging review

Close follow-up

Memory Hook:COMPRESS = Can usually Conservative Manage if only inferior cortex

Mnemonic

TRIAD - Female Athlete Risk

Training excessive (overload)

Too much too soon

Reduced energy availability

Caloric deficit

Irregular menses (amenorrhea)

Hormonal dysfunction

Absent periods red flag

Screen all female athletes

Decreased BMD

Osteopenia/osteoporosis

Memory Hook:TRIAD in female athletes = Think stress fracture and bone health

Mnemonic

FULLERTON - Classification

First degree - MRI only findings

Periosteal edema

Usually conservative

If early stage

Line visible on imaging

Higher grade

Location matters (tension vs compression)

Determines treatment

Endosteal involvement

More advanced

Radiographic fracture line

Grade 3-4

Treatment based on grade and location

Algorithm-driven

Operative if tension side or high grade

Surgical indication

Non-operative if compression and low grade

Conservative option

Memory Hook:FULLERTON classification guides treatment decisions

Overview and Epidemiology

Femoral neck stress fractures are overuse injuries occurring from repetitive submaximal loading, most common in endurance athletes and military recruits. They represent a high-risk stress fracture location due to displacement potential and AVN risk.

Historical context:

First described in military populations
Recognition of tension vs compression distinction critical
Female athlete triad identified as major risk factor

High-Risk Location

Femoral neck stress fractures are classified as high-risk stress fractures due to the risk of displacement leading to AVN and nonunion. They require more aggressive management than low-risk stress fractures (tibial shaft, metatarsal).

Epidemiology:

5% of all stress fractures
Female predominance (especially with triad)
Military recruits: 11% incidence
Distance runners: highest athletic risk
Ballet dancers: also high risk

Risk factors:

Training errors (too much, too soon)
Female athlete triad (low energy availability, amenorrhea, low BMD)
Low vitamin D
Smoking
Previous stress fracture
Rapid increase in activity

Pathophysiology and Mechanisms

Femoral neck anatomy:

The femoral neck is vulnerable to stress fractures due to:

High bending loads during weight-bearing activities
Limited blood supply (risk of AVN)
Thin cortical bone especially superiorly

Biomechanics of loading:

Superior cortex - TENSION forces:

During single-leg stance, the femoral neck experiences bending moments:

Superior cortex is under TENSION (pulling apart)
Inferior cortex is under COMPRESSION (pushing together)

Tension forces cause:

Cracks to propagate rather than close
Higher risk of complete fracture
Potential for sudden displacement

This is why tension-side stress fractures are surgical emergencies - the crack can propagate and displace suddenly.

Stress fracture pathophysiology:

Bone remodeling imbalance: Resorption exceeds formation
Microdamage accumulation: Repetitive loading
Stress reaction: Bone edema without fracture line
Stress fracture: Fracture line develops
Complete fracture: Full-thickness propagation

Early detection at stress reaction stage allows conservative management.

Classification Systems

Tension vs Compression:

Type	Location	Risk	Treatment
Tension	Superior cortex	HIGH - displacement risk	Surgical fixation
Compression	Inferior cortex	Lower	Conservative possible
Complete	Both cortices	Highest	Surgical - urgent

Location is THE key factor in management decisions. Always determine if the fracture involves the superior (tension) or inferior (compression) cortex.

Clinical Assessment

History:

Typical presentation:

Young athlete or military recruit
Insidious onset groin pain
Activity-related symptoms
Pain worse with impact activities
May have preceding prodromal ache

Key history questions:

Training history (recent increases?)
Menstrual history (females)
Dietary intake and RED-S screening
Previous stress fractures
Medication history (steroids, bisphosphonates)

RED-S Screening

In any athlete with stress fracture, screen for Relative Energy Deficiency in Sport (RED-S) - the updated term for female athlete triad. This includes low energy availability, menstrual dysfunction, and bone health issues.

Physical examination:

Key tests:

Test	Technique	Finding
Gait assessment	Observe walking	Antalgic gait
Log roll	Passive rotation in extension	Groin pain
Hop test	Single leg hop	Pain reproduction
Fulcrum test	Femur over forearm as fulcrum	Pain with loading
FABER/FADIR	Hip ROM tests	Groin pain, reduced ROM

Hop test:

Should NOT be performed if high clinical suspicion
Risk of displacing an incomplete fracture
Use clinical judgment

Hop Test Caution

The single-leg hop test can reproduce pain but risks displacing an incomplete fracture. If clinical suspicion is high, proceed directly to imaging rather than provocative testing.

Investigations

Clinical Imaging

Multimodal imaging of femoral neck stress fracture comparing X-ray and MRI — Three-panel comparison demonstrating the superiority of MRI for femoral neck stress fracture diagnosis. Panel A: Plain radiograph may appear normal or show subtle sclerosis in early stress fractures. Panels B-C: Coronal MRI sequences show obvious bone marrow edema (high signal) in the femoral neck that is not visible on X-ray. This illustrates why MRI is the gold standard - it detects stress reactions 2-4 weeks before radiographic changes appear, allowing early intervention.Credit: PMC Open Access - CC BY 4.0

MRI showing femoral neck stress fracture with bone marrow edema — Two-panel coronal MRI demonstrating right femoral neck stress fracture. The arrows indicate the area of bone marrow edema - high signal on fluid-sensitive sequences (left panel) and low signal on T1 (right panel). Location is critical: tension-side (superior cortex) fractures require prophylactic surgical fixation due to high displacement risk, while compression-side (inferior cortex) fractures may be managed conservatively with non-weight bearing.Credit: MedPix/Wikimedia Commons - Public Domain

Tension-side femoral neck stress fracture with surgical fixation — Two-panel demonstrating surgical management of a tension-side femoral neck stress fracture. Panel A: Pre-operative radiograph showing the minimally-displaced tension-sided (superior cortex) fracture. Panel B: Post-operative radiograph showing prophylactic fixation with dynamic hip screw (DHS). This case illustrates the key exam point: tension-side fractures require surgical fixation even when minimally displaced due to high risk of complete displacement and subsequent avascular necrosis (AVN).Credit: PMC Open Access - CC BY 4.0

Imaging approach:

Plain radiographs:

Often negative for 2-4 weeks
May show sclerotic line, periosteal reaction
Full-length views recommended
Compare to contralateral side

MRI (Gold Standard):

Detects stress reaction before fracture line visible
Shows bone marrow edema (T2/STIR hyperintense)
Identifies fracture line if present
Determines tension vs compression involvement
Essential for early diagnosis

MRI Findings

MRI shows bone marrow edema (bright on T2/STIR, dark on T1) in stress reactions. A fracture line appears as low signal on all sequences. Location of findings determines if tension or compression side involved.

When to order MRI:

Clinical suspicion with negative X-rays
Early diagnosis critical (athletes in-season)
Determine extent and location
Monitor healing progress

CT scan:

Better for visualizing cortical fracture lines
Less sensitive for early stress reaction
Useful if MRI contraindicated or equivocal

Bone scan:

Highly sensitive but less specific
Shows focal uptake at fracture site
Less commonly used now due to MRI availability
Cannot distinguish tension vs compression

Laboratory investigations:

Vitamin D level
Calcium
TSH (if RED-S suspected)
Consider DEXA for BMD (if triad/RED-S)

Management

SURGICAL MANAGEMENT REQUIRED:

Tension-side (superior cortex) stress fractures have high displacement risk and require prophylactic fixation.

Surgical options:

Percutaneous cannulated screws (3 parallel screws)
DHS if larger fracture
Valgus osteotomy (rarely needed)

Surgical technique:

Supine on fracture table
Image intensifier guidance
3 cannulated screws in inverted triangle
Ensure no screw in weight-bearing dome

Postoperative:

Protected weight bearing initially
Progress as healing confirmed
Return to sport when united and pain-free

Do not delay surgery for tension-side fractures.

Surgical Technique

Patient positioning:

Supine on fracture table or radiolucent table
Image intensifier access for AP and lateral
Slight internal rotation of leg
Unaffected leg in lithotomy position

Preparation:

Confirm fracture location on imaging
Mark skin incision
Ensure adequate fluoroscopy images
Prepare for closed vs open approach

Most cases can be done percutaneously with fluoroscopic guidance.

Complications

Complications of Femoral Neck Stress Fractures

Complication	Risk Factors	Prevention/Management
Displacement	Tension side, delayed diagnosis	Early surgery for tension side, non-weight bearing
Avascular necrosis	Displacement, delayed fixation	Urgent treatment, anatomic reduction
Nonunion	Displacement, inadequate fixation, metabolic factors	Revision surgery, bone grafting
Hardware failure	Inadequate fixation, early loading	Proper technique, protected weight bearing
Recurrence	Failure to address risk factors	Treat underlying causes, gradual return
Delayed union	Metabolic factors, inadequate rest	Extended non-weight bearing, optimize bone health

Avascular necrosis:

Most feared complication
Risk increases with displacement
Time to treatment matters
May occur despite optimal care
Monitor long-term

Nonunion:

More common if displaced
Risk factors: smoking, metabolic bone disease, poor fixation
Treatment: revision with bone graft, valgus osteotomy, or arthroplasty

AVN Risk

AVN risk is directly related to degree of displacement and time to treatment. Tension-side fractures have higher AVN risk because they are more likely to displace. Urgent surgical fixation minimizes this risk.

Postoperative Care and Rehabilitation

Postoperative protocol:

Week 0-6

Protected weight bearing (toe-touch or partial)
Hip ROM exercises
Core and upper body conditioning
Aquatic therapy when wound healed
Serial X-rays at 2 and 6 weeks

Week 6-12

Progress weight bearing as healing allows
X-ray to confirm early union
Stationary bike
Progressive hip strengthening
Continue cross-training

Month 3-6

Full weight bearing when united
Progress to impact activities
Running progression (if athlete)
Sport-specific training
Final MRI to confirm healing

Return to sport criteria:

Union confirmed on imaging
Full, pain-free ROM
Strength symmetry
Functional testing passed
Underlying risk factors addressed

Timeline for return:

Compression side (conservative): 3-4 months
Tension side (surgical): 4-6 months
Displaced fracture: 6-12 months (depends on AVN)

Outcomes and Prognosis

Prognostic factors:

Factor	Better Prognosis	Worse Prognosis
Location	Compression side	Tension side
Diagnosis	Early (stress reaction)	Late (complete fracture)
Displacement	Non-displaced	Displaced
Treatment timing	Urgent appropriate care	Delayed treatment
Underlying factors	Addressed	Unaddressed

Expected outcomes by type:

Compression-side (non-operative):

Union rate: 95%+ with compliance
Return to sport: 3-4 months
Long-term prognosis: Excellent if healed

Tension-side (operative):

Union rate: 90-95% with fixation
Return to sport: 4-6 months
AVN risk: 5-10% (higher if delayed)

Displaced fractures:

AVN risk: 20-30%
Outcomes worse than prophylactically fixed
May require arthroplasty if AVN develops

Prevention and Return to Sport

Primary prevention:

Training principles:

Gradual load progression (10% rule)
Adequate rest days
Cross-training to reduce impact
Proper footwear
Appropriate running surfaces

Nutritional factors:

Adequate caloric intake
Calcium: 1000-1500mg daily
Vitamin D: maintain greater than 75 nmol/L
Avoid relative energy deficiency

Female athlete screening:

Menstrual history in all female athletes
RED-S screening questionnaire
Low threshold for endocrine referral
Bone health assessment if abnormalities

Secondary prevention:

Address all modifiable risk factors
Gradual return to sport
Cross-training during recovery
Long-term bone health monitoring

Evidence Base

Tension vs Compression Side Outcomes

III

📚 Retrospective studies of femoral neck stress fractures

Key Findings:

50% displacement rate for tension side if conservative
Less than 5% displacement for compression side
Surgical fixation critical for superior cortex involvement

Clinical Implication: Supports surgical fixation for tension-side stress fractures

MRI for Early Diagnosis

📚 Prospective studies comparing imaging modalities

Key Findings:

MRI 100% sensitivity for stress fractures
X-ray only 10-40% sensitive early
MRI detects bone marrow edema before fracture line visible

Clinical Implication: MRI should be first-line imaging when clinical suspicion high

Female Athlete Triad and Stress Fractures

📚 Prospective cohort studies

Key Findings:

2-4x increased risk with female athlete triad
Low energy availability key driver
Screening all female athletes with stress fractures essential

Clinical Implication: Screen all female athletes with stress fractures for RED-S/triad

Return to Sport Outcomes

III

📚 Case series of athletes with femoral neck stress fractures

Key Findings:

85-95% return to sport rate
Better outcomes with early diagnosis
Risk factor modification improves outcomes

Clinical Implication: Good prognosis if managed correctly and risk factors addressed

Vitamin D and Stress Fracture Prevention

📚 RCT in military recruits

Key Findings:

20% reduction in stress fractures with vitamin D
Military recruits are high-risk population
Target vitamin D levels greater than 75 nmol/L

Clinical Implication: Optimize vitamin D levels in at-risk populations

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Young Runner with Groin Pain

EXAMINER

"A 22-year-old female marathon runner presents with 4 weeks of activity-related groin pain. She has increased her training significantly in the past 2 months. X-rays are negative. How do you proceed?"

EXCEPTIONAL ANSWER

This presentation of activity-related groin pain in a young female runner with recent training increase is concerning for femoral neck stress fracture until proven otherwise. My approach would include detailed history about training changes, menstrual history to screen for female athlete triad, and dietary intake. Given high clinical suspicion and negative X-rays, I would order MRI which is gold standard for early stress fracture diagnosis. I would make her non-weight bearing with crutches pending MRI results. If MRI confirms stress fracture, management depends critically on whether tension or compression side is involved - tension side requires surgical fixation while compression side can be managed conservatively.

KEY POINTS TO SCORE

MRI is gold standard when X-rays negative

Tension vs compression location determines management

Screen for female athlete triad

Non-weight bearing pending diagnosis

COMMON TRAPS

✗Missing tension-side involvement

✗Not ordering MRI due to negative X-rays

✗Missing female athlete triad screening

LIKELY FOLLOW-UPS

"MRI shows superior cortex involvement - what now?"

"How do you screen for female athlete triad?"

VIVA SCENARIOChallenging

Scenario 2: Tension-Side Stress Fracture

EXAMINER

"MRI shows bone marrow edema involving the superior cortex with a fracture line. How do you manage this?"

EXCEPTIONAL ANSWER

This is a tension-side femoral neck stress fracture involving the superior cortex with visible fracture line. This is a surgical emergency due to high risk of displacement. My management would be strict non-weight bearing immediately and urgent surgical referral for prophylactic internal fixation. I would perform percutaneous cannulated screw fixation with three screws in inverted triangle configuration under fluoroscopic guidance. Postoperatively, protected weight bearing progressing as healing allows. I would also address underlying risk factors - review training program, optimize bone health with vitamin D and calcium, and arrange endocrinology review for female athlete triad screening.

KEY POINTS TO SCORE

Tension side = surgical emergency

Percutaneous cannulated screws

Three screws in inverted triangle

Address underlying risk factors

COMMON TRAPS

✗Attempting conservative management for tension side

✗Delaying surgery

✗Not addressing underlying causes

LIKELY FOLLOW-UPS

"What configuration do you use for screws?"

"What if she develops AVN at 1 year?"

VIVA SCENARIOChallenging

Scenario 3: Failed Conservative Management

EXAMINER

"A 25-year-old male military recruit was diagnosed with compression-side femoral neck stress fracture and has been non-weight bearing for 6 weeks. Follow-up imaging shows fracture line progression. What do you do?"

EXCEPTIONAL ANSWER

This represents failure of conservative management with fracture progression despite appropriate non-weight bearing protocol. I would now convert to surgical management with percutaneous cannulated screw fixation. The fracture has shown it will not heal with conservative measures and continued non-operative treatment risks displacement. I would counsel the patient about the need for surgery, perform fixation with three cannulated screws, and ensure protected weight bearing postoperatively. I would also thoroughly investigate why healing failed - check vitamin D levels, screen for metabolic bone disease, and review nutritional status. Military recruits are high-risk population and may have underlying factors contributing to poor healing.

KEY POINTS TO SCORE

Progression despite conservative care = surgery needed

Don't persist with failing conservative treatment

Investigate underlying metabolic factors

Same surgical technique as primary fixation

COMMON TRAPS

✗Continuing conservative management despite progression

✗Not investigating why healing failed

✗Missing metabolic bone disease

LIKELY FOLLOW-UPS

"What vitamin D level would you aim for?"

"When can he return to military training?"

MCQ Practice Points

Tension vs Compression

Q: Which side of the femoral neck requires prophylactic fixation? A: The tension side (superior cortex). It has a high risk of displacement (50 percent) and subsequent AVN. Compression side (inferior cortex) fractures are more stable and can often be managed conservatively.

MRI Sensitivity

Q: What is the gold standard imaging for suspected stress fracture with negative X-rays? A: MRI. It has 100 percent sensitivity and detects bone marrow edema weeks before a fracture line is visible on X-ray (which has only 10-40 percent sensitivity early on).

Female Athlete Triad

Q: What are the components of the Female Athlete Triad? A: Low energy availability, menstrual dysfunction, and low bone mineral density. This increases stress fracture risk by 2-4x and must be screened for in all female athletes.

Surgical Configuration

Q: What is the recommended screw configuration for femoral neck fixation? A: Three cannulated screws in an inverted triangle pattern. This provides optimal stability. Screws must assume a position along the calcar and avoid the weight-bearing dome.

Vitamin D Target

Q: What is the target Vitamin D level for stress fracture healing? A: Greater than 75 nmol/L. Levels below this impair bone healing and increase recurrence risk. Supplementation is part of standard management.

AVN Risk

Q: which factor most strongly correlates with AVN risk? A: Displacement. The degree of displacement and time to reduction/fixation determines the risk of vascular disruption to the femoral head.

Australian Context

Australian sports medicine considerations:

Common populations:

Australian Rules Football players
Distance runners
Military personnel (ADF)
Ballet dancers

Medicare/PBS:

MRI requires referral for Medicare rebate
Vitamin D testing and supplementation covered
DEXA for at-risk individuals

Sports medicine pathway:

Sports medicine physician initial assessment
Orthopedic referral for surgical cases
Multidisciplinary approach for RED-S/triad
Sports dietitian involvement

Return to sport guidelines:

AIS (Australian Institute of Sport) protocols
Team sport medical clearance requirements
Individual sport governing body requirements

Key resources:

Sports Medicine Australia guidelines
AIS clinical resources
RANZCOG guidelines for female athlete health

Exam Cheat Sheet

Femoral Neck Stress Fractures

High-Yield Exam Summary

Key Decision - Tension vs Compression

•TENSION (superior cortex) = SURGERY
•COMPRESSION (inferior cortex) = Conservative possible
•Tension side has 50 percent displacement risk if not fixed
•Compression side has less than 5 percent displacement risk
•This is THE exam question - get it right!

Diagnosis

•MRI is gold standard (X-rays often negative)
•Bone marrow edema on T2/STIR (early sign)
•Fracture line visible in higher grades
•Full-length femur X-ray to rule out shaft involvement
•Determine tension vs compression involvement

Surgical Technique

•Three cannulated screws (6.5-7.3mm)
•Inverted triangle configuration
•Fluoroscopic guidance (AP and Lateral)
•No screw in weight-bearing dome
•Posterior cortex engagement essential

Female Athlete Triad/RED-S

•Low energy availability (dietary)
•Menstrual dysfunction (amenorrhea)
•Low bone mineral density (osteopenia)
•Screen ALL female athletes with stress fractures
•involve sports dietitian and endocrinologist

Complications

•AVN - related to displacement degree
•Nonunion - metabolic factors/smoking
•Recurrence - if risk factors not addressed
•Hardware failure if early weight bearing
•Coxa vara deformity if reduction lost

Return to Sport

•Union confirmed on imaging (MRI/CT)
•Pain-free with activity and hop test
•Underlying causes addressed (Vitamin D)
•Gradual return with cross-training
•Typically 3-6 months depending on severity

Fracture Type

Location

Treatment

Tension-side stress fracture

Superior cortex involvement

SURGICAL - prophylactic screw fixation

Compression-side stress fracture

Inferior cortex only

Non-weight bearing 6-8 weeks, serial imaging

Displaced fracture

Complete with displacement

Urgent surgical fixation (cannulated screws or DHS)

Compression side - not healing

Progressive symptoms at 6 weeks

Convert to surgical fixation

Bilateral stress reaction

Both hips affected

Address underlying cause, extended rest

Type

Location

Risk

Treatment

Tension

Superior cortex

HIGH - displacement risk

Surgical fixation

Compression

Inferior cortex

Lower

Conservative possible

Complete

Both cortices

Highest

Surgical - urgent

Test

Technique

Finding

Gait assessment

Observe walking

Antalgic gait

Log roll

Passive rotation in extension

Groin pain

Hop test

Single leg hop

Pain reproduction

Fulcrum test

Femur over forearm as fulcrum

Pain with loading

FABER/FADIR

Hip ROM tests

Groin pain, reduced ROM

Clinical Imaging

Imaging approach:

Plain radiographs:

Often negative for 2-4 weeks
May show sclerotic line, periosteal reaction
Full-length views recommended
Compare to contralateral side

MRI (Gold Standard):

Detects stress reaction before fracture line visible
Shows bone marrow edema (T2/STIR hyperintense)
Identifies fracture line if present
Determines tension vs compression involvement
Essential for early diagnosis

MRI Findings

When to order MRI:

Clinical suspicion with negative X-rays
Early diagnosis critical (athletes in-season)
Determine extent and location
Monitor healing progress

CT scan:

Better for visualizing cortical fracture lines
Less sensitive for early stress reaction
Useful if MRI contraindicated or equivocal

Bone scan:

Highly sensitive but less specific
Shows focal uptake at fracture site
Less commonly used now due to MRI availability
Cannot distinguish tension vs compression

Laboratory investigations:

Vitamin D level
Calcium
TSH (if RED-S suspected)
Consider DEXA for BMD (if triad/RED-S)

Complication

Risk Factors

Prevention/Management

Displacement

Tension side, delayed diagnosis

Early surgery for tension side, non-weight bearing

Avascular necrosis

Displacement, delayed fixation

Urgent treatment, anatomic reduction

Nonunion

Displacement, inadequate fixation, metabolic factors

Revision surgery, bone grafting

Hardware failure

Inadequate fixation, early loading

Proper technique, protected weight bearing

Recurrence

Failure to address risk factors

Treat underlying causes, gradual return

Delayed union

Metabolic factors, inadequate rest

Extended non-weight bearing, optimize bone health

Factor

Better Prognosis

Worse Prognosis

Location

Compression side

Tension side

Diagnosis

Early (stress reaction)

Late (complete fracture)

Displacement

Non-displaced

Displaced

Treatment timing

Urgent appropriate care

Delayed treatment

Underlying factors

Addressed

Unaddressed

Grade	MRI Findings	X-ray	Management
1	Periosteal edema only	Negative	Activity modification
2	Periosteal + bone marrow edema	Negative	Non-weight bearing
3	Fracture line visible on MRI	± Positive	Location-dependent
4	Complete fracture	Positive	Surgical

Grade	Bone Scan	MRI	X-ray
1	Mild uptake	STIR positive	Normal
2	Moderate uptake	STIR and T2 positive	Normal
3	Marked uptake	T1 and T2 abnormal	Normal to positive
4	Intense uptake	Fracture line visible	Positive

Grade	MRI Findings	X-ray	Management
1	Periosteal edema only	Negative	Activity modification
2	Periosteal + bone marrow edema	Negative	Non-weight bearing
3	Fracture line visible on MRI	± Positive	Location-dependent
4	Complete fracture	Positive	Surgical

Grade	Bone Scan	MRI	X-ray
1	Mild uptake	STIR positive	Normal
2	Moderate uptake	STIR and T2 positive	Normal
3	Marked uptake	T1 and T2 abnormal	Normal to positive
4	Intense uptake	Fracture line visible	Positive