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Treatment of Fatigue Fracture of the Bilateral Femoral Neck

Posted on: 11/30/1999
Fatigue fractures, also called stress fractures, are caused by overusing a limb. The muscles become unable to absorb the shock to the limb (usually the leg) and the bone itself begins to take the brunt of it. Because the bone isn't built for this, it eventually cracks. However, the elderly can also develop fatigue fractures but they aren't caused by over use, rather they are usually caused by insufficiency, meaning there isn't enough muscle to help protect the bones.

The authors of this article reviewed a patient who had a fatigue fracture. A 61-year-old woman was complaining of right hip pain but hadn't fallen or had any type of accident that may have caused it. She was still able to walk and function. The doctors did find pain and some swelling in the hip joint and, while the hip moved well upwards, moving it out and in was impossible due to the pain the movements caused. X-rays and magnetic resonance imaging (MRI) then confirmed that there was a fracture, which was diagnosed as a fatigue fracture.

The patient was operated on and was able to resume her normal state of functioning after two months and she felt back to normal after four months.

There were many theories about what caused fatigue fractures in older patients, from muscle fatigue and loss to new and different activities. One researcher, Pentecoste and colleagues, came up with three common characteristics of patients who sustained fatigue fractures of the hip. They were: new and different activity, strenuous activity, or repeated activity, making the same motions over and over. In this patient's case, the authors felt that her job as a cleaning lady for the previous five years could have been the cause, given the bending and squatting she had to do in the course of her day.

When doctors are assessing patients with hip pain but the patients aren't limping nor are they in any significant pain, they must keep in mind that fatigue fractures are so subtle that they may not even appear in the x-ray. Therefore, it would probably be a good idea to follow up the x-ray with an MRI or a bone scintigraphy (a test that uses dye to look at the bone).

The hip fatigue fracture has been divided into three classifications: tension, compression, and displaced. Displaced fractures mean that the bone has moved. A group of researchers, Devas, Bickenstaff and Morris, and Fullerton and Snowdy, recommended that patients with compression-type fractures not undergo surgery, as well as those who had tension without opening (in the bone). If the tension fracture did have opening or the patient had a displaced fracture, then surgery would be recommended. Another option is traction and bedrest for some types of tension fractures.

The authors didn't feel that these recommendations fit their particular patient because the recommendations were based on younger patients and only with one side of the joint fractured. Their patient had a bilateral fracture, which meant two sides were broken on the bone. There is also a concern about leaving an older patient on bedrest for long periods of time, at least three weeks, as this can cause other problems and delays in overall healing.

As with all surgeries, there are complications associated with hip surgery. These include the bones not joining (nonunion), refracture, or bone death of the femoral head, the ball of the hip joint. However, statistics aren't too reliable as several researchers have come up with differing findings as to how often these occur.

In conclusion, the authors wrote that they recommend surgery for older patients with bilateral hip fatigue fracture and that if a fatigue fracture is suspected, x-rays should be followed by an MRI for clarification.

Jiro Ichikawa, MD, PhD, et al. Fatigue Fracture of the Bilateral Femoral Neck in the Elderly. In Orthopedics. November 2008. Vol. 31. Pp. 1141-1142.

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