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Journal of Pediatric Orthopaedics B:
doi: 10.1097/BPB.0b013e328358b2c8
Pelvis, Hip & Femur

Stress fracture of the femoral neck in a child: a case report

Fiévez, Erik F.P.A.a; Hanssen, Nicole M.A.I.b; Schotanus, Martijn G.M.c; van Haaren, Emil H.c; Kort, Nanne P.c

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Author Information

aDepartment of Orthopaedic Surgery, Atrium Medical Center, Heerlen

bDepartment of Orthopaedic Surgery, Laurentius Hospital, Roermond

cDepartment of Orthopaedic Surgery, Orbis Medical Center, Sittard, The Netherlands

Correspondence to Erik F.P.A. Fiévez, MD, Department of Orthopaedic Surgery, Atrium Medical Center, Postbus 4446, 6401CX Heerlen, The Netherlands Tel: +31 88 4597777; fax: +31 45 5766055; e-mail: e.fievez@gmail.com

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Abstract

A 7-year-old boy developed complaints of pain in the left groin. These complaints started spontaneously. Initial plain radiographs of the pelvis indicated no abnormalities. As the symptoms persisted for 6 weeks, the young patient and his parents visited our institution. Clinical investigation showed a slight extension deficit of the left hip. New radiographs and MRI indicated a fracture line with sclerosis along the inferior border of the left femoral neck. In retrospect, this stress fracture of the femoral neck was also visible on the initial radiographs. Seven months after the onset of complaints in the left groin and prescribed partial weight bearing with crutches, callus formation with consolidation of the femoral neck was observed on radiographs. Eleven months after onset, the patient recovered fully without any residual symptoms. After 21 months, the young patient did not have any complaints or restrictions in physical activity. Because of its highly rare nature, stress fractures of the femoral neck in children are easy to miss initially. This was also applicable in our case. Extensive differential diagnosis of a child with pain in the groin furthermore adds to the difficulty in the diagnosis of a stress fracture of the femoral neck. This case report emphasizes the importance of the evaluation of radiographs and observation in children with hip complaints. Similarly, interdisciplinary consultation and cooperation between the general practitioner, orthopaedic surgeon, radiologist and paediatrician is essential in the diagnosis, evaluation and treatment of these young patients.

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Introduction

Stress fractures commonly affect highly physically active adults such as young athletes, military recruits, but also patients with metabolic bone diseases 1–3. These fractures are rarely seen in children with an open capital femoral epiphysis. Only a few case series have reported on a huge number of children diagnosed with stress fractures. These studies reported that the tibia, fibula, femur and metatarsals are commonly affected. Among stress fractures in children, fractures of the femoral neck are even rarer. Since the first case was described by Devas in 1963, less than 20 of these case series have been published 4–14. This case report presents a 7-year-old boy with a stress fracture of the femoral neck.

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Case report

In October 2010, a 7-year-old boy visited the general practitioner with complaints of pain in the left groin following a short period of physical activity. These complaints started spontaneously, 2 weeks earlier. There was no previous history of illness, trauma, or other contributing factors. Plain radiographs of the pelvis indicated no abnormalities according to the radiological report, which was sent to the general practitioner, although a slight sclerotic line could be distinguished along the left femoral neck (Fig. 1a and b).

Fig. 1
Fig. 1
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Six weeks later, the patient was referred to the orthopaedic department, because of persisting pain in the left groin. Besides an additional limp after about 10 min of physical exercise, the symptoms were unaltered. Physical examination only showed a slight extension deficit of the left hip. New radiographs indicated a fracture line with an area of sclerosis along the inferior border of the left femoral neck (Fig. 2a and b). MRI was carried out to confirm the diagnosis and to exclude any soft tissue involvement. The MRI showed a hypointense line with an area of hyperintense signalling on the inferior border of the femoral neck, along with a small cortical interruption (Fig. 3a and b). There was no sign of any soft tissue damage. The young patient was treated with partial weight bearing on crutches and temporary discontinuation of physical activities. However, normal skeletal images do not rule out metabolic bone disease. Extensive additional research was carried out by the paediatric department, to exclude metabolic bone diseases. There were no signs of malnutrition, organic failure or metabolic bone diseases.

Fig. 2
Fig. 2
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Fig. 3
Fig. 3
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Seven months after the onset of complaints, the young patient had no residual symptoms and radiographs showed callus formation with consolidation of the femoral neck (Fig. 4a and b). Our patient was free from pain and started participating in sports again, 11 months after the onset of initial complaints. Twenty-one months after onset, the parents were consulted by phone. The young patient was still free of complaints and participated in sports.

Fig. 4
Fig. 4
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Discussion

In 1963, Devas 4 was the first to describe a stress fracture of the femoral neck in a child. He was also the first to distinguish between two types of stress fractures of the femoral neck: a transverse fracture and a compression fracture 1. Transverse fractures, also known as tension fractures, show a cortical interruption in the superior cortex of the femoral neck. These fractures are prone to displacement and therefore require immediate surgical fixation. One case described a child with a tension fracture of the femoral neck, who was treated with cannulated screws 14. In comparison, compression fractures are identified as a cortical interruption in the inferior cortex of the femoral neck. As these fractures are stable, they only require partial or non-weight-bearing treatment with crutches. As presented in our case, stress fractures of the femoral neck in children are often compression fractures in which only one side is affected 4–7,9–13. The overall prognosis of compression-type fractures is good. Patients with asymptomatic fractures generally return back to their previous level of activity after several months. Little is known about the pathophysiological process that causes stress fractures. Increased incidence of (atypical) fractures in children is often associated with underlying conditions affecting the bone structure 2,8. However, no reports of underlying medical conditions for a femoral stress fracture in children exist in the literature 3,5–7,9–14. Also, in our patient, no underlying medical condition could be identified. Because of its highly rare nature, stress fractures in children are easily misdiagnosed. Stress fractures can often resemble malignant lesions, especially sarcoma and osteomyelitis, or radiological abnormalities such as fibrous cortical defects or nonossifying fibroma 10,15. Altogether, femoral stress fractures in young patients with open capital epiphysis of the femur is a very difficult and unlikely diagnosis in children with groin pain. The differential diagnosis for a child with groin pain is extensive and other diagnoses such as Perthes disease, arthritis, synovitis, slipped capital femoral epiphysis, osteomyelitis and malignancies are far more likely. Nevertheless, this case emphasizes the importance of good clinical observation and interpretation of radiographs in children. Interdisciplinary consultation between the general practitioner, orthopaedic surgeon, radiologist and paediatrician is important in the diagnosis, evaluation and treatment of these young patients.

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Acknowledgements
Conflicts of interest

There are no conflicts of interest.

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References

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14. Lehman RA, Shah SA. Tension-side femoral neck fracture in a skeletally immature patient; a case report. J Bone Joint Surg Am. 2004;86:1292–1295

15. Shimal A, Davies AM, James SL, Grimer RJ. Fatigue-type stress fractures of the lower limb associated with fibrous cortical defects/non-ossifying fibromas in the skeletally immature. Clin Radiol. 2010;65:382–386

Keywords:

child; epiphysis; fracture; femoral neck; hip; stress; stress fracture

© 2013 Lippincott Williams & Wilkins, Inc.

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