Displaced stress fracture of the femoral neck in an active amenorrhoeic adolescent

Energy, Waves, and Forces in Bilateral Fracture of the Femoral Necks: Two Case Presentations and Updated Critical Review

Two case reports and an updated critical review on bilateral fractures of the femoral neck are presented. Bilateral fractures of the femoral neck have been investigated for at least 80 years and are treated as rare cases. The primary cause is usually considered an external shock; however, aside from high energy shocks (e.g., falling and impact with hard, rigid surfaces, traffic accidents, etc.) the underlying causes of femoral neck frailty have not yet been fully understood. Although not exhaustive, the review spans cases reported as early as 1944 and compares their conclusions in line with medicine developments at the time of the reports until present. The discussion is perhaps controversial at times; it brings to the fore the energy balance between shock waves and stress waves. The two cases reported here add to the review, one highlighting the biomechanics, and the other supporting more recent findings on metabolic disorders, which ultimately lead to enhanced frailty of the femoral neck. Investigation of the fractures has been performed with X-ray radiographs, MRI, and CT, with a follow up using a Doppler US to check blood flow in the lower zone of the limbs. The second case was investigated both for fractures and metabolic diseases, e.g., type I diabetes and kidney failure (dialysis). In Case 1 the second fracture was not observable at the time of admission, and therefore two surgery operations were performed at seven days interval. Taperloc Complete prostheses (Zimmer Biomet) were applied. Case 2 suffered a second fracture in the right hip in the segment above the knee and required better fixation with cables. Despite this, she returned one month later with a new crack in the femur. Case 1 is a typical case of wear consequences on the biomechanics of the hill pad-tibia-femur-femoral neck system, where tension of the neck occurred due to a stress wave rather than a shock wave. This can be proven by the absence of a second fracture from the images first acquired, the only evidence being pain and walking difficulty. Case 2 shows that metabolic diseases can dramatically enhance the frequency of bilateral femoral neck fractures.

[Femoral neck stress fractures and femoroacetabular impingement : A retrospective case study and literature review]

BACKGROUND

Femoroacetabular impingement (FAI) can lead to morphologic damage of both the acetabulum and the femoral neck. Recent reports have found an association between impingement deformities and the development of femoral neck stress fractures. The aim of this study was to report a series of patients with these findings and to update the current evidence on the topic.

MATERIAL AND METHODS

5 patients (6 cases) with atraumatic femoral neck fractures and FAI were identified in the Dresden hip registry from 2015 to 2018. Demographic data, comorbidities, radiographic results and bone metabolism results were described. A literature search was conducted using keywords related to femoral neck stress fractures and FAI syndrome.

RESULTS

The average age of the series was 39 (range: 22-52), 2 patients were female and 3 male. A total of 12 surgical procedures were performed. 4 of the 5 patients showed radiographic features of pincer and/or cam-FAI, whereas 3 patients had a decreased femoral antetorsion (-7° to +7° antetorsion). In 3 patients, magnetic resonance imaging revealed additional signs of avascular necrosis ARCO I. There was a lack of FAI-specific treatment recommendations in the available literature.

DISCUSSION

Radiographic results of the patients evaluated suggested that impingement-associated deformities of the hip may cause femoral neck stress fractures, which is in line with the available literature. This potential coincidence should be integrated in diagnostic algorithms and therapeutic approaches.

Lower Extremity Compartment Syndrome in National Football League Athletes

BACKGROUND

The purpose of this study was to evaluate the incidence of lower extremity compartment syndrome in National Football League (NFL) athletes and report the mechanisms of injury, methods of treatment, and subsequent days missed. We review the existing literature on lower extremity compartment syndrome in athletic populations.

HYPOTHESIS

Lower extremity compartment syndrome occurs with a low incidence in NFL athletes, and there is a high return-to-play rate after surgical management of acute compartment syndrome.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

A retrospective review of recorded cases of lower extremity compartment syndrome from 2000 to 2017 was performed using the NFL Injury Surveillance System and electronic medical record system. Epidemiological data, injury mechanism, rates of surgery, and days missed due to injury were recorded.

RESULTS

During the study period, 22 cases of leg compartment syndrome in 21 athletes were recorded. Of these injuries, 50% occurred in games and 73% were the result of a direct impact to the leg. Concomitant tibial fracture was noted in only 2 cases (9.1%) and there was only 1 reported case of chronic exertional compartment syndrome. Surgery was documented in 15 of 22 cases (68.2%). For acute nonfracture cases, the average time missed due to injury was 24.2 days (range, 5-54 days), and all were able to return to full participation within the same season.

CONCLUSION

NFL athletes with acute leg compartment syndrome treated with surgery exhibited a high rate of return to play within the same season.

CLINICAL RELEVANCE

Although compartment syndrome is a relatively rare diagnosis among NFL players, team physicians and athletic trainers must maintain a high index of suspicion to expediently diagnose and treat this potentially limb-threatening condition.

Bilateral concomitant femoral neck stress fracture in a sedentary patient with anorexia nervosa

A 27 years old sedentary woman presented bilateral femoral neck stress fractures after having clinically recovered from anorexia nervosa and was treated with bilateral internal fixation.

Conclusion

Although light exercise is usually considered after recovery from anorexia nervosa to improve bone quality, this case of a sedentary patient suggests that weight gain, per se, could increase the stress fracture risk. Because of the physiological and psychological characteristics, these patients should be treated with a multi-disciplinary approach.

Accuracy of self-reported physical activity in patients with anorexia nervosa: links with clinical features

BACKGROUND

High levels of physical activity (PA) have long been described in patients with Anorexia Nervosa (AN). Despite the importance of measuring PA in this population, there are two important factors that remain unknown. First, it is not clear how accurate self-report measures of PA are among patients. Second, little is known about how clinical characteristics are associated with the accuracy of self-reported PA. Therefore, this study aimed to examine the accuracy of self-reported PA compared to an objective measure of PA in patients with AN. It also investigated whether levels of accuracy/inaccuracy were associated with compulsive exercise, motivation to change, and psychological distress.

METHOD

Data were analysed from 34 adult outpatients with AN. Patients wore an accelerometer device (ActiGraph) for 4 days and completed a retrospective self-report measure of exercise (Exercise Participation Screening Questionnaire). They also completed measures of compulsive exercise (Compulsive Exercise Test), motivation to change (The Anorexia Nervosa Stages of Change Questionnaire), and psychological distress (Kessler-10).

RESULTS

On the self-report measure, patients accurately reported their time spent in moderate and vigorous intensity PA, however, they significantly under-reported their light physical activity (compared to the accelerometer data). Accurate reporting of total PA was positively associated with higher levels of compulsive exercise. There was evidence to suggest that clinical features, such as motivation to change and psychological distress, may be associated with inaccurate reporting at some levels of PA intensity and not others.

CONCLUSIONS

Results indicate that patients with AN are likely to under-report their light intensity PA. We also found preliminary evidence for how compulsive exercise, motivation to change, and distress are associated with self-reported PA accuracy. Clinical implications and directions for future research are considered.

TRIAL REGISTRATION

ACTRN12610000585022. Taking a LEAP forward in the treatment of anorexia nervosa: a randomized controlled trial. NHMRC grant: 634922.

Clinical Trials Required to Assess Potential Benefits and Side Effects of Treatment of Patients With Anorexia Nervosa With Recombinant Human Leptin

The core phenotype of anorexia nervosa (AN) comprises the age and stage dependent intertwining of both its primary and secondary (i.e., starvation induced) somatic and mental symptoms. Hypoleptinemia acts as a key trigger for the adaptation to starvation by affecting diverse brain regions including the reward system and by induction of alterations of the hypothalamus-pituitary-“target-organ” axes, e.g., resulting in amenorrhea as a characteristic symptom of AN. Particularly, the rat model activity-based anorexia (ABA) convincingly demonstrates the pivotal role of hypoleptinemia in the development of starvation-induced hyperactivity. STAT3 signaling in dopaminergic neurons in the ventral tegmental area (VTA) plays a crucial role in the transmission of the leptin signal in ABA. In patients with AN, an inverted U-shaped relationship has been observed between their serum leptin levels and physical activity. Albeit obese and therewith of a very different phenotype, humans diagnosed with rare congenital leptin deficiency have starvation like symptoms including hypothalamic amenorrhea in females. Over the past 20 years, such patients have been successfully treated with recombinant human (rh) leptin (metreleptin) within a compassionate use program. The extreme hunger of these patients subsides within hours upon initiation of treatment; substantial weight loss and menarche in females ensue after medium term treatment. In contrast, metreleptin had little effect in patients with multifactorial obesity. Small clinical trials have been conducted for hypothalamic amenorrhea and to increase bone mineral density, in which metreleptin proved beneficial. Up to now, metreleptin has not yet been used to treat patients with AN. Metreleptin has been approved by the FDA under strict regulations solely for the treatment of generalized lipodystrophy. The recent approval by the EMA may offer, for the first time, the possibility to treat extremely hyperactive patients with AN off-label. Furthermore, a potential dissection of hypoleptinemia-induced AN symptoms from the primary cognitions and behaviors of these patients could ensue. Accordingly, the aim of this article is to review the current state of the art of leptin in relation to AN to provide the theoretical basis for the initiation of clinical trials for treatment of this eating disorder.

Femoral Neck Fractures in Children: A Review

Paediatric femoral neck fractures are uncommon injuries and are usually caused by high-energy trauma. Low-energy trauma can result in pathologic neck fractures and stress fractures of the neck, due to repetitive activity. Surgical options can vary based on age, Delbet classification and displacement of the fracture. Treatment for displaced fractures is by closed or open reduction and smooth/cancellous screw fixation. Compression screw and side plate fixation is indicated for basal fractures. Fixation should be supplemented by spica cast immobilization in younger children. The high rate of complications occurs due to the vascular anatomy of the hip and proximal femur. Avascular necrosis, coxa vara, premature physeal closure, and nonunion are the most common and these often result in poor outcome.

Femoral Neck Stress Fractures in Sport: A Current Concepts Review

Femoral neck stress fractures (FNSFs) account for 3% of all sport-related stress fractures. The commonest causative sports are marathon and long-distance running.

The main types of FNSF are compression-sided, tension-sided and displaced. The most common reported symptom is exercise-related groin pain. Radiographs form the first line of investigation, with MRI the second-line investigation.

The management of FNSFs is guided by the location and displacement of the fracture. Delay in diagnosis is common and increases the likelihood of fracture displacement. Sporting outcomes are considerably worse for displaced fractures. Education programmes and treatment protocols can reduce the rates of displaced FNSFs.

This article aims to provide a current concepts review on the topic of FNSFs in sport, assess the current evidence on the epidemiology and pathophysiology of these injuries, detail the current recommendations for their imaging and management, and review the recorded sporting outcomes for FNSFs in the existing literature.

From this study, we conclude that although FNSFs are a rare injury, they should be considered in all athletes presenting with exercise-related hip pain, because delay in diagnosis and subsequent fracture displacement can significantly impair future return to sport. However, when detected early, FNSFs show promising results in terms of return-to-sport rates and times.

Management of Severe Rhabdomyolysis and Exercise-Associated Hyponatremia in a Female with Anorexia Nervosa and Excessive Compulsive Exercising

This case report describes the management of a 49-year-old female with restricting-type anorexia nervosa and excessive compulsive exercising associated with rhabdomyolysis, high levels of serum creatine kinase (CK) (3,238 U/L), and marked hyponatremia (Na⁺: 123 mEq/L) in the absence of purging behaviours or psychogenic polydipsia; it is the first case report to describe exercise-associated hyponatremia in a patient with anorexia nervosa. The patient, who presented with a body mass index (BMI) of 13.4 kg/m², was successfully treated by means of an adapted inpatient version of an enhanced form of cognitive behavioural therapy (CBT-E). Within a few days, careful water restriction, solute refeeding, and the specific cognitive behavioural strategies and procedures used to address the patient's excessive compulsive exercising and undereating produced a marked reduction in CK levels, which normalised within one week. Exercise-associated hyponatremia also gradually improved, with serum sodium levels returning to normal within two weeks. The patient thereby avoided severe complications such as cerebral or pulmonary oedema or acute renal failure and was discharged after 20 weeks of treatment with a BMI of 19.0 kg/m² and improved eating disorder psychopathology.

A clinical profile of compulsive exercise in adolescent inpatients with anorexia nervosa

BACKGROUND

The aim of the current study was to contribute to the development of a clinical profile of compulsive exercise in adolescents with Anorexia Nervosa (AN), by examining associations between compulsive exercise and eating and general psychopathology.

METHOD

A sample of 60 female adolescent inpatients with AN completed a self-report measure of compulsive exercise and a series of standardized self-report questionnaires assessing eating and general psychopathology.

RESULTS

Higher levels of compulsive exercise were associated with increased levels of eating disorder psychopathology and anxiety. Specifically, the avoidance aspect (negatively reinforced) of compulsive exercise was associated with elevated scores on measures of eating disorder, anxiety, depression, and obsessive compulsiveness psychopathology, as well as lower self-esteem scores. The mood improvement value (positively reinforced) of compulsive exercise, however, did not reflect such trends.

CONCLUSIONS

Compulsive exercise driven by avoidance of negative affect is associated with more severe psychological features in adolescent inpatients with AN. The current findings emphasize the need for research and clinical efforts in the development of treatments addressing avoidance of negative affect and compulsive exercise in adolescents with AN.

High Levels of Physical Activity in Anorexia Nervosa: A Systematic Review

High level physical activity is a frequent symptom in patients with anorexia nervosa (AN), influencing the development, maintenance, complications, treatment success, relapse rate and severity of the disease. Accelerometry is assumed to be an objective method to assess physical activity (PA) in AN. We aimed to review objectively measured levels of PA in AN and to give an overview for clinical practice and future research. Data were searched in PubMed and PsychINFO until April 2015 following the preferred reporting items for systematic reviews and meta-analyses statement. Twenty studies fulfilled the inclusion criteria. A notable heterogeneity of measurements, outcomes, participants and settings was found. Overall, HLPA is not adressed enough by current evidence. A common valid terminology of HLPA is not available, and accurate criteria of different levels of PA must be defined to create comparability of future studies. Further objective PA assessments are needed to improve treatment outcome and relapse rate.

Perspectives of Canadian fitness professionals on exercise and possible anorexia nervosa

BACKGROUND

Many individuals with eating disorders, including anorexia nervosa (AN), engage in overexercise. Little is known about fitness professionals' perceptions of their responsibilities when interacting with clients with possible AN. The purpose of the current study was to examine Alberta fitness professionals' experiences with clients suspected of having AN, and their views on related ethical issues. Specifically, we aimed to examine (1) their experiences with fitness clients suspected of having AN; (2) their opinions about related ethical responsibilities of fitness professionals; and (3) their views on related training and ethical issues.

METHODS

We administered a 21-item online survey to 143 Canadian fitness professionals about their experiences and perspectives on encountering individuals with possible AN in exercise classes and at their exercise facilities.

RESULTS

Sixty-two percent of respondents had encountered a client they believed had AN. Three-quarters had never received any training on managing clients with AN and felt inadequately prepared for such situations. Although most felt ethically obliged to intervene with such a client, more than two-thirds reported no relevant guidelines in their professional training.

CONCLUSIONS

Many fitness professionals are faced with clients with possible AN, have the desire to help, feel ethically obligated to take action, but do not know what course of action to take, if any. Work is needed to clarify ethical issues and related training needs for certification programs for fitness professionals regarding AN.

Bilateral femoral neck fractures after an epileptic attack: A case report

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Bilateral femoral neck fractures may occur following grand mal epilepsy attack in young patients.

Introduction

Bilateral femoral neck fractures can occur due to high- or low-energy trauma, in the presence of various predisposing factors, such as osteoporosis, renal osteodystrophy, hypocalcemic seizures, primary or metastatic tumors, electroconvulsive therapy, epileptic seizures, and hormonal disorders.

Presentation of case

This report presents a case of bilateral femoral neck fractures that occurred during an epileptic attack in a 24-year-old male with mental retardation. His complaints had started after a grand mal epileptic attack 10 days earlier. Bilateral displaced femoral neck fractures (Garden type 4) were seen in lateral radiographs of both hips. The patient was operated on urgently, with closed reduction, three stainless steel cannulated screws, and internal fixation applied to both hips. At postoperative week 12, solid joining was achieved and active walking with complete loading was started.

Discussion

Bilateral femoral neck fractures can occur following a grand mal epilepsy attack in young patients. The use of antiepileptic drugs can also lead to the development of pathological fractures by reducing bone mineral density.

Conclusion

Femoral neck fractures should be suspected in patients with epilepsy who present with severe pain in both hips and an inability to walk. Stainless steel implants can be used for treatment. The viability of the femoral head should be evaluated by scintigraphy. Bone mineral density should be monitored in patients who use anti-epileptic drugs, and internal fixation is preferred in the treatment of femoral neck fractures.

Assessment of physical activity in anorexia nervosa and treatment outcome

PURPOSE

The aim of this study was to compare objective and subjective assessments of physical activity (PA) in patients with anorexia nervosa and its effect on treatment outcome.

METHODS

Both Actiheart (AH) and International Physical Activity Questionnaire (IPAQ) were used to assess PA in 52 female patients with anorexia nervosa during the first week of inpatient treatment.

RESULTS

No correspondence between PA estimated by IPAQ, which had a tendency to underestimate PA, and that measured using AH emerged. However, a significant association was found between the change in Eating Disorder Examination global score at the end of the treatment and light PA measured by AH (beta = -0.12, t = -2.44, P = 0.019), but not that estimated by IPAQ.

CONCLUSIONS

PA in patients with anorexia nervosa is underestimated by subjective assessment when compared with objective measurement. Only time spent in light PA, assessed objectively with AH, showed a negative association with improvement in eating disorder psychopathology.

2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indianna) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Expert Panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, and the American Medical Society for Sports Medicine.

Bilateral Pseudarthrosis of the Femoral Neck in a 25-Year-Old Male with Hereditary Hypophosphatemic Rickets

Hereditary hypophosphatemic rickets (HHR) is a rare disorder of renal phosphate wasting and the most common form of heritable rickets. Here, we report a case of an active 25-year-old male with HHR showing atraumatic bilateral femoral neck pseudarthrosis after 4 years of consecutive knee pain. A conservative therapy was administered, taking into account both the risks of surgical treatment and the little impairment even in the sport activities which the patient experienced.

Eating disorders, physical fitness and sport performance: a systematic review

Background: Eating disorders are health problems that are particularly prevalent in adolescents and young adults. They are associated with considerable physical health and psychosocial morbidity, and increased risk of mortality. We set out to conduct a systematic review to determine their effect on physical fitness in the general population and on sport performance in athletes. Methods/Design: A systematic review of the relevant peer-reviewed literature was performed. For inclusion, articles retrieved from PubMed had to be published in English between 1977 and 2013. Wherever possible, methods and reporting adhere to the guidelines outlined in the PRISMA statement. Some additional studies were retrieved from among those cited in the reference lists of included studies and from non-electronic databases. Literature searches, study selection, method and quality appraisal were performed independently by two authors, and data was synthesized using a narrative approach. Results: Of the 1183 articles retrieved, twenty-nine studies met the inclusion criteria and were consequently analysed. The available data indicate that eating disorders have a negative effect on physical fitness and sport performance by causing low energy availability, excessive loss of fat and lean mass, dehydration, and electrolyte disturbance. Discussion: Although the paucity of the available data mean that findings to date should be interpreted with caution, the information collated in this review has several practical implications. First, eating disorders have a negative effect on both physical fitness and sport performance. Second athletics coaches should be targeted for education about the risk factors of eating disorders, as deterioration in sport performance in athletes, particularly if they are underweight or show other signs of an eating disorder, may indicate the need for medical intervention. However, future studies are needed, especially to assess the direct effect of eating disorders on sport performance.

Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: a 5-year prospective study in collegiate track and field athletes

BACKGROUND

Bone stress injuries are common in track and field athletes. Knowledge of risk factors and correlation of these to magnetic resonance imaging (MRI) grading could be helpful in determining recovery time.

PURPOSE

To examine the relationships between MRI grading of bone stress injuries with clinical risk factors and time to return to sport in collegiate track and field athletes.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

A total of 211 male and female collegiate track and field and cross-country athletes were followed prospectively through their competitive seasons. All athletes had preparticipation history, physical examination, and anthropometric measurements obtained annually. An additional questionnaire was completed regarding nutritional behaviors, menstrual patterns, and prior injuries, as well as a 3-day diet record. Dual-energy X-ray absorptiometry was performed at baseline and each year of participation in the study. Athletes with clinical evidence of bone stress injuries had plain radiographs. If radiograph findings were negative, MRI was performed. Bone stress injuries were evaluated by 2 independent radiologists utilizing an MRI grading system. The MRI grading and risk factors were evaluated to identify predictors of time to return to sport.

RESULTS

Thirty-four of the athletes (12 men, 22 women) sustained 61 bone stress injuries during the 5-year study period. The mean prospective assessment for participants was 2.7 years. In the multiple regression model, MRI grade and total-body bone mineral density (BMD) emerged as significant and independent predictors of time to return to sport. Specifically, the higher the MRI grade (P = .004) and lower the BMD (P = .030), the longer the recovery time. Location of the bone injury at predominantly trabecular sites of the femoral neck, pubic bone, and sacrum was also associated with a prolonged time to return to sport. Female athletes with oligomenorrhea and amenorrhea had bone stress injuries of higher MRI grades compared with eumenorrheic athletes (P = .009).

CONCLUSION

Higher MRI grade, lower BMD, and skeletal sites of predominant trabecular bone structures were associated with a delayed recovery of bone stress injuries in track and field athletes. Knowledge of these risk factors, as well as nutritional and menstrual factors, can be clinically useful in determining injury severity and time to return to sport.

A displaced femoral neck stress fracture in an amenorrheic adolescent female runner

This case demonstrates the potential serious consequences of the female athlete triad and its effects on bone. Displaced femoral neck stress fractures cause significant morbidity, and this case highlights the preventable nature of this injury. The treatment was focused on improving low energy availability, and, although challenging, improvements were made. This injury could have been prevented if the signs and symptoms of her injury had been addressed and there had been better knowledge of her risk factors. This case highlights the need for further education in the sports and health communities.

Pseudarthrosis of femoral neck stress fracture treated with open reduction, sliding hip screw and bone morphogenic protein

INTRODUCTION

Pseudarthrosis of femoral neck stress fractures in young adults are associated with a high incidence of complications and revision surgery. The majority are treated urgently with closed reduction and internal fixation.

PRESENTATION OF CASE

We describe a displaced tension-type femoral neck fatigue fracture presenting late. Pseudarthrosis formation prior to surgery resulted in resorption and shortening of the femoral neck. Open reduction and internal fixation was performed, with adjuvant recombinant human bone morphogenic protein-7 therapy. Radiological union was achieved by twelve weeks and by one year the patient was asymptomatic.

DISCUSSION

Reports of successful management of femoral neck fatigue fracture non-unions are rare. Meyer's muscle pedicle graft, valgus subtrochanteric osteotomy, and cannulated screw fixation with autologous iliac crest bone graftare alternative procedures.

CONCLUSION

This extremely rare fracture type merits open reduction to enable accurate fracture reduction. Supplementing sliding hip screw fixation with an orthobiological agent was successful in this challenging situation.

Displaced stress fracture of the femoral neck in young active adults

Stress fractures of the femoral neck in healthy individuals are rare and most prevalent among long-distance runners and military recruits. Women seem to be at higher risk of developing stress fractures because of possible eating disorders and, thereby, following amenorrhoea and osteoporosis. The majority of fractures of the femoral neck are undisplaced. However, they might progress into displaced fractures with avascular necrosis of the femoral head and following development of osteoarthritis as a probable consequence even when treated properly. Early diagnosis with MRI or radionuclide scanning in patients with a history of pain in the groin region during training might be crucial in detecting the fractures at early stages; thereby preventing possible complications following surgical treatment of displaced fractures. The authors present a report of two young adults who developed displaced fractures of the femoral neck and were treated with closed reduction and internal fixation.

Features and management of compulsive exercising in eating disorders

Compulsive exercising is a common feature of patients with eating disorders. It is reported more frequently by patients with restricting-type anorexia nervosa than with other eating disorders. It is associated with higher eating disorder psychopathology, dietary restraint, general psychopathology, and specific personality features (ie, higher levels of perfectionism, persistence, and lower novelty seeking). It is a potent maintaining mechanism of eating disorder psychopathology, and it increases the risk of overuse injuries, bone fractures, and cardiac complications. It also appears to be a predictor of poor treatment outcome. Literature are lacking regarding its treatment, but cognitive-behavioral therapy in its enhanced form appears to be a promising treatment in hospitalized patients.

Emergencies in adolescents: management guidelines for four presentations

The cases presented in this article are representative of adolescent emergencies that may be encountered by the office practitioner. Many more examples in the area of adolescent gynecology could have been presented, including ectopic pregnancy and pelvic inflammatory disease. Substance abuse issues will be addressed in the second part of this topic, which will be published in the December 2005 issue of Pediatric Annals. Consultation with an adolescent medicine specialist is always recommended for challenging cases.

Stress fractures in women

Stress fractures are common overuse injuries, reported more frequently in female athletes than in male athletes. The clinician should have a high index of suspicion for this injury whether an athlete presents with complaints of acute pain and disability or insidious onset of pain that is aggravated by activity and relieved by rest. Radiographs, bone scans, CT scans, and MR imaging may all be useful in confirming the diagnosis. Conservative treatment is usually successful, although one must be especially vigilant in treating a stress fracture prone to complications. Identifying risk factors for susceptibility to stress fracture development may help to avoid recurrence of the injury. More research is needed to determine cause versus association of these various risk factors in relationship to stress injury to bone.