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C OPYRIGHT Ó 2021 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Tension-Sided Femoral Neck Stress Fracture

in an Adolescent with Vitamin D Deficiency
and Osteomalacia
Downloaded from http://journals.lww.com/jbjscc by k38zdtHxkv4GqUtrpBilxmqdJ33q2Na+36qVoYuWTEZ6YFqRPbzQU55uRYh1x4ne+3ogVPI8KCwzGHNQ2jW7jxocTJFXjSs8sfhveTzYyYmf/BgP5lRkaUy2C3ks40l03ZJbomxmNEQ= on 01/05/2022

A Case Report
Neeraj Vij, BS, Ashish S. Ranade, MBBS, MS (Ortho), Supriya Gupte, MBBS, MD, Gauri A. Oka, MBBS, MPH, and
Mohan V. Belthur, MD, FRCSC, FRCS (Tr & Orth)

Investigation performed at Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India

Abstract
Case: An adolescent girl presented with groin pain without any history of trauma. Imaging showed a tension-sided stress
fracture of the femoral neck. Vitamin D deficiency (VDD), and raised alkaline phosphatase and parathyroid hormone levels
were found. Pain relief was not achieved with nonoperative treatment. Considering the risk of fracture progression and
displacement, the fracture was fixed with cannulated cancellous screws. Fracture healed without any complications.
Conclusion: A tension-sided femoral neck stress fracture, with VDD and osteomalacia, is a rare cause of hip pain in an
adolescent. Surgical fracture stabilization is necessary in addition to medical treatment.

F
emoral neck stress fractures (FNSFs) are rare in children1.
The FNSF could be of compression side or tension side,
with the latter being uncommon2,3. FNSFs are generally
believed to be predisposed by athletic activity or metabolic
bone diseases4-6. Vitamin D deficiency (VDD) may affect the
bone architecture that may predispose to a stress fracture7.
Fracture associated with metabolic bone diseases is either a
medial compression-type FNSF or a complete neck femur
fracture5,6. To the best of our knowledge, there is no report of a
tension-sided FNSF associated with VDD and osteomalacia in
an adolescent.
In contrast to compression-type fractures, tension-sided
FNSFs carry the risk of progression to complete fracture and
displacement at the fracture site. We report a case of an adolescent
girl with a tension-sided FNSF with osteomalacia and VDD.
The patient and her parents were informed that data
concerning the case would be submitted for publication, and
they provided consent.
Case Report
had persisted despite activity modification and rest. The patient
had no known medical conditions. She attained menarche at 12
years with regular cycles. The patient’s height was 141 cm, and
weight was 46 kg (body mass index of 23.1 kg/m2). Physical
examination revealed a normal-appearing right lower
extremity. The right hip terminal flexion was mildly painful.
Internal and external rotations were pain-free, and the range of
motion was symmetrical in both the hips. There was no
obligatory external rotation.
The radiographs showed a transverse fracture involving
the superior side of the femoral neck (tension-type fracture)
(Fig. 1 and Fig. 2). The fracture was incomplete and non-
displaced. The MRI demonstrated a partial fracture involving
the superior part of the femoral neck, minimal effusion in the
hip joint, and edema in the femoral neck (Figs. 3 and 4). There
were no radiological signs of osteomalacia. Radioisotope bone
scan was not performed. Blood tests revealed vitamin D levels
(25(OH) vitamin D) 6 ng/dL (reference range, 20-50 ng/dL),
serum ionic calcium 4.64 mg/dL (reference range, 4.4-5.5 mg/dL),
serum calcium 8.4 mg/dL (reference range, 8.4-10.2 mg/dL),

A 15-year-old girl presented with complaints of right hip

pain. There was no history of trauma or sports activity.
The pain was present for the past 8 months. The pain was rated
serum phosphorous 2.75 mg/dL (reference range, 2.3-4.7), and
serum alkaline phosphatase 321 IU/L (reference range, 47-149
IU/L). Bone-specific alkaline phosphatase was not performed.
as mild and increased with activities such as climbing stairs and Liver and renal function tests, and serum electrolytes were
Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B540).
Keywords: stress fracture, femoral neck, adolescent, hip pain, osteomalacia, hypovitaminosis D, pediatric, vitamin D deficiency, tension-sided femoral
neck stress fracture

JBJS Case Connect 2021;11:e20.00787 d http://dx.doi.org/10.2106/JBJS.CC.20.00787

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Fig. 1
Fig. 1 Anteroposterior radiographic view of the pelvis demonstrating a tension-sided (lateral) fracture of the right femoral neck. Fig. 2 Frog pelvic view
showing a stress fracture along the anterior aspect neck of the femur.
within the normal range. The parathyroid hormone (PTH)
level was 276.5 pg/mL (reference range, 10-76 pg/mL) sug-
gestive of compensatory secondary hyperparathyroidism. Total
leukocyte count was 8,700/mm3 (reference range, 4,000-
10,000/mm3), and CRP was 0.5 mg/L (reference range, 0-3 mg/L).
We did not do bone mineral density studies or bone biopsy.
The patient was also evaluated by a pediatric endocrinologist.
The patient was diagnosed to have a tension-sided FNSF with
VDD and osteomalacia. The diagnosis of osteomalacia was
made based on the criteria by Uday and Högler [high alkaline
phosphatase, high PTH, low dietary calcium intake, and/or
low serum 25OH (<30 nmol/L)]8. The differential diagnoses
considered in a case of chronic right hip pain for 8 months in
an adolescent were infectious causes (sclerosing osteomyeli-
tis), inflammatory arthropathy, slipped capital femoral
epiphysis, delayed traumatic presentation, and osteoid oste-
oma. In the given case, the imaging confirmed the diagnosis
of a tension-sided FNSF.
Fig. 3
Fig. 3 Axial and coronal MRI T2 images at presentation demonstrating a tension-sided femoral neck stress fracture. The axial view shows edema and
capsular effusion. Fig. 4
T E N S I O N -S I D E D F E M O R A L N E C K S T R E S S F R A C T U R E
Fig. 2
Nonoperative treatment with non–weight-bearing
ambulation and vitamin D 60,000 IU once every week for
10 weeks along with calcium 500 mg daily for 12 weeks was
started. The patient continued to have persistent pain and
difficulty in maintaining non–weight-bearing ambulation.
Considering inadequate pain relief with nonoperative mea-
sures and the risk of progression of the tension-sided FNSF to
complete fracture and displacement, a decision was made to
stabilize the fracture surgically. The fracture was stabilized with
two 6.5-mm partially threaded, cannulated cancellous screws
to achieve compression across the fracture site (Fig. 5). Post-
operatively, the patient was allowed to ambulate toe-touch
weight-bearing with crutches for 6 weeks and then transitioned
to full weight-bearing over the next 6 weeks.
The patient recovered well with no complications and
became pain-free at 2 weeks after the surgery. After completion
of treatment for VDD, a repeat biochemical profile at
5 months showed normalization of vitamin D levels and
Fig. 4
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Fig. 5
Postoperative anterior-posterior radiographic view of the pelvis after per-
cutaneous placement of two 6.5-mm screws.
alkaline phosphatase levels and resolution of secondary
hyperparathyroidism. Thereafter, calcium 250 mg daily and
vitamin D 400 IU were prescribed based on the recommen-
dation of Khadilkar et al9. The PTH and other biochemical
parameters remained normal at 30-month follow-up. Radi-
ographs obtained at the 30-month follow-up showed healed
fracture without any signs of osteonecrosis (Figs. 6 and 7). At
Fig. 6
Fig. 6 Anteroposterior and frog pelvic radiographs obtained at 30-month follow-up showing the united femoral neck stress fracture. Fig. 7
T E N S I O N -S I D E D F E M O R A L N E C K S T R E S S F R A C T U R E
30-month follow-up, the patient remains pain-free. We con-
tinue to keep close follow-up.
Discussion
W e present an unusual case of a tension-sided FNSF in an
adolescent girl with VDD and osteomalacia. Pediatric
FNSFs are rare, and a majority are associated with overuse in
sports1,3,4. Repetitive cyclical loading of the hip joint leads to a
stress fracture. Other causes of FNSFs include osteomalacia,
VDD, and rickets5,6. The FNSFs are classified into compression-
type (fracture along the inferomedial side of the femoral neck)
and tension-type (a vertical fracture along the superior side of
the femoral neck)2.
Children with FNSFs present with hip or referred knee
pain with or without a limp. There might not be a history of
increased sports activity before the onset of symptoms10. Clinical
examination shows a slight limitation of hip movements. A
radiograph may show linear sclerosis or callus formation in the
femoral neck; however, it may be absent during the initial few
weeks. A stress fracture may progress with continued activity to a
complete fracture and also may become displaced.
Diagnosing FNSFs in a child is challenging, given the
minimal findings on clinical examination and subtle changes in the
radiographs. MRI is the key investigation to achieve early diagnosis.
Although most of the FNSFs tend to heal with nonoperative
treatment, fractures involving the tension side are at increased risk
of fracture completion or displacement. Treatment should aim to
avoid this complication. The presence of a tension-sided fracture
or fracture with hip joint effusion is the risk factor for developing a
complete fracture, and fracture stabilization is recommended.
Tension-sided stress fracture or fracture with involvement of >50%
of the femoral neck is at high risk of displacement and is recom-
mended to undergo surgical stabilization11,12.
Laboratory investigations to rule out metabolic causes
should include vitamin D (25OH) levels, serum calcium,
serum alkaline phosphatase, and serum PTH levels, in addition
Fig. 7
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to other investigations. Osteomalacia is characterized by low
vitamin D level, raised alkaline phosphatase, normal or low
serum calcium level, and raised serum PTH level in an indi-
vidual after skeletal maturity. In a child with open physis, the
same laboratory picture is seen in rickets. Various diagnostic
criteria have been described including several biochemical
markers and bone biopsy findings8.
A high prevalence of VDD (>80%) has been reported in
Indian school-going children (age group, 6-17 years)13. This
deficiency was believed to be a result of multiple factors such as
dietary deficiency, lack of sun exposure, and genetic factors13,14.
There are no guidelines regarding the type of questions a clinician
should ask to help screen for VDD in an otherwise healthy-
appearing adolescent. Also, there is insufficient evidence for
pediatric healthcare providers to recommend which VDD risk
factors should be used for screening in children and adolescents15.
An association between osteomalacia and FNSFs in ado-
lescents has been reported5,6. A study has reported a compression-
type FNSF in a 14-year-old girl with VDD. The patient was treated
nonoperatively, and 18 months later, the fracture healed5. In
another report, a complete and displaced femoral neck fracture in
association with low levels of vitamin D has been described6.
Notably, neither of these reports demonstrated any radiological
features of osteomalacia on pelvic radiographs or MRI. This
probably suggests that the pathological process within the bones
that predisposes to pediatric FNSFs may precede the development
of the radiologic features. The only reported case of a tension-
sided FNSF is of a 14-year-old boy. There was no metabolic
abnormality in this patient, and the fracture was believed to have
developed after participating in a football camp. This fracture was
treated surgically using cannulated compression screws3.
The tension-sided FNSF tends to be unstable, given their
anatomic position and forces leading to a higher propensity to
develop a complete fracture with displacement3. A displaced
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Neeraj Vij, BS1
Ashish S. Ranade, MBBS, MS (Ortho)2
Supriya Gupte, MBBS, MD3
Gauri A. Oka, MBBS, MPH4
Mohan V. Belthur, MD, FRCSC, FRCS (Tr & Orth)5
1University of Arizona College of Medicine, Phoenix, Arizona
2Blooming Buds Center for Pediatric Orthopaedics, Deenanath
Mangeshkar Hospital and Research Center, Erandwane, Pune,
Maharashtra, India
3Department of Pediatric Endocrinology, Deenanath Mangeshkar
Hospital and Research Center, Erandwane, Pune, Maharashtra, India
4Research Consultant, Deenanath Mangeshkar Hospital and Research
Center, Erandwane, Pune, India
5Department of Pediatric Orthopaedics, Phoenix Children’s Hospital,
Phoenix, Arizona
E-mail address for A.S. Ranade: ranadea2@gmail.com
ORCID iD for N. Vij: 0000-0002-7214-0411
ORCID iD for A.S. Ranade: 0000-0003-0925-6427
ORCID iD for S. Gupte: 0000-0003-0594-1558
ORCID iD for G.A. Oka: 0000-0003-3425-8512
ORCID iD for M.V. Belthur: 0000-0001-5279-0591
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