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Femoral Stress Fracture

General Information


  • stress fractures are fractures that develop due to repetitive strain on healthy or unhealthy bones, usually occurring in the lower extremities1,2,4,5
    • fatigue fractures are stress fractures caused by repetitive or excessive stress on otherwise healthy bones
    • pathologic or insufficiency fractures are stress fractures caused by the normal stress of daily activities on bone weakened by conditions including osteomalacia, osteoporosis, Paget disease of bone, and other less common conditions
  • locations of femoral stress fracture can include2,4
    • femoral neck (more common)
    • femoral shaft (more common)
    • femoral head
    • lesser trochanter
    • greater trochanter
    • femoral condyle stress fractures near the knee

Also called

  • femoral fatigue fracture
  • femoral insufficiency fracture


  • fatigue-type stress fractures are stress fractures due to repetitive strain on an otherwise healthy bone5
  • pathologic or insufficiency fractures are stress fractures in an unhealthy bone; types include5
    • Looser zone stress fracture5
      • insufficiency-type stress fracture often associated with osteomalacia
      • often presents with multiple, symmetric stress fractures
      • have been incorrectly called pseudo-fractures
      • characterized by broader band of lucency, parallel margins, and minimal marginal sclerosis
      • associated with delayed healing
    • atypical insufficiency-type fracture with appearance of Looser zones5
      • stress fractures that appear like Looser zones stress fractures but patient does not have osteomalacia
      • usually occurs as a single stress fracture
    • atypical femoral fracture5
      • femoral stress fractures associated with bisphosphonate therapy for osteoporosis
      • stress fracture located in femoral diaphysis in the area just distal to the lesser trochanter to the area just proximal to the supracondylar flare
      • must meet 4 of the following 5 major criteria according to American Society for Bone and Mineral Research task force
        • associated with minimal or no trauma
        • fracture line starts at the lateral cortex where it is mainly transverse although it may become oblique as it travels medially across the femur
        • completed fracture extends through both cortices, but incomplete fractures only involve the lateral cortex
        • fracture non-comminuted (not broken into multiple pieces) or only minimally comminuted
        • localized periosteal or endosteal thickening of lateral cortex present at fracture site
  • Study Summary
    no standard classification system available for stress fractures
    • based on systematic review of studies and review articles evaluating stress or fatigue fractures and their classification Systematic Review
    • systematic review of 43 studies and review articles evaluating stress or fatigue fractures and their classification
    • 27 different classification systems were identified
    • no classification system had statistical analysis of inter-observer or intra-observer reliability
    • PubMed21378491The Physician and sportsmedicine20110201Phys Sportsmed3919393 Reference - 21378491Phys Sportsmed 2011 Feb;39(1):93


General references used

  1. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician. 2011 Jan 1;83(1):39-46full-text
  2. Pegrum J, Crisp T, Padhiar N. Diagnosis and management of bone stress injuries of the lower limb in athletes. BMJ. 2012 Apr 24;344:e2511full-text
  3. Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress fractures of the pelvis and legs in athletes: a review. Sports Health. 2013 Mar;5(2):165-74full-text
  4. Tins BJ, Garton M, Cassar-Pullicino VN, Tyrrell PN, Lalam R, Singh J. Stress fracture of the pelvis and lower limbs including atypical femoral fractures-a review. Insights Imaging. 2015 Feb;6(1):97-110full-text
  5. McKenna MJ, Heffernan E, Hurson C, McKiernan FE. Clinician approach to diagnosis of stress fractures including bisphosphonate-associated fractures. QJM. 2014 Feb;107(2):99-105full-text
  6. Shane E, Burr D, Abrahamsen B, Adler RA, et al. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2014 Jan;29(1):1-23full-text

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