Bilateral Simultaneous Femoral Neck Stress Fracture Despite Clinical Recovery from Anorexia Nervosa: A Case Report

Bilateral femoral neck stress fractures in elderly individuals: A case report and literature review

RATIONALE

Bilateral femoral neck stress fractures are relatively rare injuries that occur frequently in military recruits, athletes and patients with osteoporosis, renal bone disease, metabolic bone disease, and chronic steroid use. Herein, a case of an elderly patient with bilateral femoral neck stress fractures is reported.

PATIENT CONCERNS

A 65-year-old man presented to the author's hospital with right hip pain for over a month. The patient was a farmer, had a long history of field labor before the onset of pain, denied any history of trauma.

DIAGNOSIS

The patient was diagnosed with a right subcapital fracture of the femoral neck after examination. The patient complained of only right hip symptoms, and hip computed tomography showed no abnormalities in the left hip. A tension fracture of the left femoral neck was missed due to unawareness of the abnormal signal of the left femoral neck seen on right hip magnetic resonance imaging.

INTERVENTIONS

During the first hospitalization, the patient underwent total hip arthroplasty (THA) on the right hip. Two months after the operation, the patient started to have pain in the left hip and underwent left THA again for a displaced left femoral neck fracture.

OUTCOMES

The patient eventually underwent bilateral THA surgery and had a satisfactory functional recovery. But the oversight in the diagnostic process led to the patient undergoing left THA that could have been avoided.

LESSONS

For patients who complain of hip pain but deny a history of trauma, we should be concerned about the presence of a hip fracture even if the patient's radiograph does not report a positive result. The most sensitive method is bilateral magnetic resonance imaging examination of the hip. Femoral neck stress fractures require early diagnosis and treatment to prevent complications.

Femoral neck stress fracture return to activity and the effect of metabolic dysfunction on recovery: A systematic review

Background

Femoral neck stress fractures are rare fractures traditionally found in athletes and military personnel. There is limited literature on return to activity.

Objectives

To report return to activity rates and times, and long-term outcomes for femoral neck stress fractures reported in the literature. To examine the effects of bone metabolic dysfunction and surgical management on return to activity following FNSF.

Research design & methods

A systematic literature review of case reports and case series on adults with femoral neck stress fracture that were diagnosed by gross fracture line on X-ray or gold-standard diagnosis with MRI was conducted. Initial search was limited to articles published from January 1997 to Jan 2023 listed in Medline, Embase, and Scopus. Additional articles were manually added via search of retained paper sources. Patient demographics, fracture type, return to activity time, and surgical vs non-surgical treatment modality were collected. In addition, long-term outcomes and metabolic effects, if reported, were abstracted.

Results

A total of 40 case reports or case series were retained. 123 stress fractures of the femoral neck from 103 patients were compiled. Of the 103 patients, data on return to activity at least one year following treatment was available for 53 patients. 71% (37/53) of those with long-term follow-up information returned to full pre-injury activity. 24% (13/53) at long-term follow-up had functional recovery but did not return to pre-injury activity due to residual pain. 4% (3/53) had disabling pain. Metabolic workup information was available for 36 patients.

Conclusion

Long-term follow-up and return to activity information following FNSF treatment are not commonly reported. Based on the available data, outcomes appear benign with most returning to full activity. There is a clear need for standardization of follow-up periods and hip function measure after FNSF treatment. Additionally, a sizable proportion of FNSF occurred in a new population of low-activity individuals with abnormal bone metabolism, which warrants further exploration.

Multiple stress fractures of unilateral femur: A case report

BACKGROUND

Stress fractures of the femoral neck are not common in clinical practice, and simultaneous stress fractures of the femoral neck and proximal femur of the unilateral femur are even more rare. We introduce a case of this type of fracture that was treated in our department, analyze the causes, and review similar stress fractures reported in the literature to provide references for the diagnosis and treatment of such conditions.

CASE SUMMARY

A 62-year-old female, with a free medical history, was admitted to the hospital mainly due to pain in the right hip and worsening pain in the right thigh. The patient had no obvious history of trauma. X-ray and computed tomography showed fracture of the femoral neck and proximal femur. The patient had undergone surgery 1 year prior to address a fracture of the left proximal femur that had occurred in a traffic accident. Our first consideration was stress fracture of the femoral neck; however, simultaneous stress fractures of the femoral neck and proximal femur of the unilateral femur were seen. The femoral neck stress fracture was a tension fracture, with obvious displacement and varus deformity of the hip. Considering that the patient was an elderly female, we performed total hip arthroplasty. Follow-up X-rays showed that the stress fracture of the proximal femur had mostly healed after 3 mo.

CONCLUSION

Muscle fatigue and hip varus deformity provide an anatomical basis for the occurrence of femoral neck stress fractures.

Femoral Neck Stress Fractures in Athletes and the Military

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Femoral neck stress fractures (FNSFs) are an infrequent condition in athletic and military populations.

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A high index of suspicion with liberal use of magnetic resonance imaging (MRI) is vital for early recognition and treatment initiation.

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An associated hip effusion on MRI is a risk factor for an evolving stress injury and requires close assessment and consideration for repeat MRI.

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Stress reactions and stable, incomplete FNSFs (<50% of femoral neck width) can be treated nonsurgically.

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Surgical intervention is accepted for high-risk, incomplete (≥50% of femoral neck width), and complete FNSFs.

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Overall, there is a paucity of high-quality literature on the rates of return to activity following FNSF.

Bone marrow in orthopaedics (part II): a three hundred and seventy million-year saga from the Devonian to the coronavirus disease 2019 pandemic-osteonecrosis; transplantation; "human chimera"; stem cells, bioreactors, and coronavirus disease

PURPOSE

Three hundred seventy million years ago, bone marrow appeared in skeleton of a fish. More than one hundred years ago, the concept of bone marrow transplantation was proposed to treat human diseases. During the last five decades, this concept became a reality first in hematology and later for orthopaedic diseases.

MATERIAL AND METHODS

These advances were possible due to the comprehension of the three major components of bone marrow: the fat part, the haematologic part, and the stroma part. Each part has a different history, but the three parts are linked in physiology as in history.

RESULTS

During many centuries, bone marrow was considered just as food; however, one hundred years ago, the concept of bone marrow transplantation to treat humans was proposed by the French physician Brown-Séquard. During the last five decades, this concept became a reality first in haematology and later for orthopaedic diseases. Transferring what was known from experimental animal models to humans was met with many challenges, the atomic bomb research, and many deaths. Yet through the recognition and subsequent understanding of fundamental processes, medical resiliency, and the determination of a few pioneers, local bone marrow transplantation in orthopaedic surgery became a therapeutic option first for a limited number of diseases and patients. Over the last two decades, mesenchymal stromal cells (MSCs) have been the focus of intense research by acadaemia and industry due to their unique features. MSCs can be easily isolated and expanded through in vitro culture by taking full advantage of their self-renewing capacity. In addition, MSCs exert immunomodulatory effects and can be differentiated into various lineages, which makes them highly attractive for clinical applications in cell-based therapies.

CONCLUSION

In this review, we attempted to provide a historical overview of bone marrow history, MSC discovery, characterization, and the first clinical studies conducted.

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.

Low-velocity simultaneous bilateral femoral neck fracture following long-term antiepileptic therapy: A case report

BACKGROUND

Simultaneous bilateral femoral neck fractures are relatively rare injuries. They are usually associated with underlying metabolic bone disorders or systemic diseases. Long-term use of narcotics and bisphosphonates can also result in similar fracture patterns; however, association of this fracture type with long-term use of antiepileptic drugs is not very common. Only one such case has been reported in the literature. This article describes the second.

CASE REPORT

We report a case of simultaneous displaced bilateral femoral neck fractures in a 50-year-old epileptic patient, who had taken phenytoin for the past 3 years. The fractures were a result of low-velocity injury following a fall from the bed. The fractures were managed with a bilateral hemi-replacement arthroplasty. Oral bisphosphonates were given to improve the bone quality in the post-operative period. The patient had a good post-operative outcome, that was sustained throughout the entire follow-up period of 1 year.

CONCLUSION

Antiepileptic drugs should be supplemented with bisphosphonates and vitamin D to improve bone quality and prevent fractures in epileptic patients.

Bilateral spontaneous simultaneous femoral neck occult fracture in a middle-aged man due to osteoporosis and vitamin D deficiency osteomalacia: A case report and literature review

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Physicians should take spontaneous femoral neck occult fracture into consideration if they report groin pain or difficulty in walking, even when findings from plain X-ray are normal.

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In a patient with spontaneous femoral neck occult fracture, diagnosing and treating the underlying etiology of osteoporosis and osteomalacia are essential for improving prognosis.

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This is the first report of a case of bilateral spontaneous simultaneous occult fracture of the femoral neck caused by osteoporosis and osteomalacia in a middle aged man.

Introduction

Bilateral stress fracture of the femoral neck is very rarely seen in healthy young patients who are neither athletes nor military recruits.

Presentation of case

The present report describes a 51-year-old male patient, not an athlete and with no previous history of disease, who developed bilateral stress fracture of the femoral neck without displacement.

Discussion

Simultaneous bilateral femoral neck fracture is a rare injury. In the present case, two factors predisposed to bilateral occult fracture of the femoral neck. The first was osteoporosis due to the patient’s smoking and alcohol abuse. The second was vitamin D deficiency osteomalacia associated with inadequate sun exposure.

Conclusion

All patients who present with spontaneous hip pain should be evaluated for osteoporosis and osteomalacia and assessed for underlying occult fracture if they report groin pain or difficulty in walking, even when findings from plain X-ray are normal, to improve prognosis in this rare and serious condition.

Ayurvedic Medications as Accelerating Cause of Atraumatic Bilateral Femur Neck Fracture in a Young Indian Male with Kidney Disease: A Unique Case Report

Introduction

In chronic renal failure, plasma 1,25-hydroxyvitamin D levels decrease due to the disturbance of the hydroxylation of 25-hydroxyvitamin D in the kidney, which results in decreased calcium absorption from the intestine. This induces hypocalcemia, which increases the secretion of parathyroid hormone. Parathyroid hormone can stimulate bone resorption which renders the bone susceptible to fractures even with trivial trauma.

Case Report

The present case describes a 41-year-old male who was diagnosed with chronic kidney disease for 6 months and started taking Ayurvedic medications after the diagnosis was established. The patient was a known hypertensive for 10 years and the patient was not taking medications for hypertension. The patient had a trivial trauma 2 months back following which he was able to walk and carry out his daily activities. He developed pain over both the hip joints which were gradually progressive and pain increased to the point, wherein the patient was unable to walk 1 month after the episode of trivial trauma. The patient was admitted for inability to walk and a radiographic study of the pelvis revealed bilateral femur neck fracture. Since the left hip was more symptomatic, the patient underwent total hip replacement of the left hip first following which total hip replacement of the right hip was done 4 days after the first surgery. The patient started ambulating full-weight-bearing with the help of a height adjustable walker from the very next day after total hip replacement of the right hip.

Conclusion

Although Ayurvedic medications have been in practice since centuries, their side effects need to be documented correctly. This particular case suggests the role of Ayurvedic medications in accelerating osteoporosis of the proximal femur, leading to bilateral femur neck fractures.