STRESS FRACTURES OF THE LOWER EXTREMITY

tures in athletes is to halt the cycle of repetitive trauma. After an appropriate trial of rest, athletes may return to their sport through gradual resumption of activity. In addition, nutritional, hormonal and medical abnormalities need to be assessed. Medical evaluation is obtained for patients with increased risk factors, including athletes with recurrent stress fractures, female athletes and stress fractures with delayed healing times. Hormonal supplementation with oral contraceptives, nutritional counseling or other medical treatments may be necessary . In certain problematic stress fractures, surgery may be required to obtain healing.
The ideal treatment of stress fractures is through prevention. Coaches, parents and athletes all need to be educated about the harmful effects of over-training and the importance of periodic rest days.


COMMON STRESS
FRACTURES

The femoral neck, femoral shaft, tibia (shin) and foot are common sites of stress fracture.

FEMORAL NECK FRACTURES
The femur is the fourth most common site of stress fractures following the tibia, the tarsals and the metatarsals (bones of the foot). Femoral stress fractures may occur in the femoral neck, the subtrochanteric area (the region below the trochanters, two projections of the upper femur that serve as attachments for muscles), or rarely the femoral condyles (the knob-like projections of the lower femur that contribute to the knee joint). (See Figure 1.)

 Patients with stress fractures of the femoral neck present with pain in the groin, anterior thigh or occasionally the knee. The pain may be exacerbated with weight bearing or physical activity. On physical examination, these patients usually have pain in the groin with internal and external rotation of the leg. Stress fractures of the femoral neck may be divided into two types: compression and distraction. The distinction between these two patterns is important because of differing treatment.

COMPRESSION FRACTURES
Compression stress fractures occur on the inferior aspect of the femoral neck and are more common in younger patients. These stress fractures rarely propagate across the femoral neck and are successfully treated with nonoperative therapy such as rest, crutches and pain medication as needed.


DISTRACTION FRACTURES
Distraction stress fractures are more common in older patients. They are characterized radiographically by a lesion in the superior cortex or tension side of the femoral neck. Early diagnosis of a distraction femoral neck stress fracture is critical, since these lesions may propagate across the femoral neck leading to a complete fracture. Unlike compression stress fractures, distraction stress fractures should be treated with open reduction and internal fixation to avoid displacement of the fracture. Complications such as delayed union and avascular necrosis (death of bone tissue due to interrupted blood supply) may develop following an untreated displaced fracture.
NO.5-FEBRUARY 1999
5:59
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