Research Paper Title

Displaced Femoral Neck Stress Fractures in Royal Marine Recruits – Management and Results of Operative Treatment.

Background

Femoral neck stress fractures (FNSF) represent 3.5%-8% of stress fractures in military recruits; potentially resulting in medical discharge and/or complications. The incidence of displaced FNSF in the British Army has been reported as 1.8 in 10,000 recruits.

Method

We aimed to review the incidence and outcome of displaced FNSF in Royal Marine recruits. Retrospective review identified 6 recruits who sustained a displaced FNSF from 2001 to 2011 representing an incidence of 9.3 in 10,000 recruits.

Results

All were treated urgently by internal fixation. There were no cases of avascular necrosis, no surgical complications and no further procedures required. All united with a mean time to union of 11 months. 50% had a union time greater than 1 year. These fractures are slow to unite but with urgent surgical intervention and stable fixation 100% union was achieved.

Conclusion

Awareness of this guides the management and rehabilitation whilst avoiding the risks of unnecessary secondary surgical interventions.

What about the Non-military Population

The highest incidence of stress fractures has been reported in runners, accounting for 4.4%-15.6% of all injuries in this population (Callahan, 2000) Overall, 95% of stress fractures involve the lower extremities (Sallis & Jones, 1991). In a study by Matheson et al. (1987), the tibia was the most common injury site, comprising 49.1%. This was followed by the tarsals (25.3%), metatarsals (8.8%), femur (7.2%), fibula (6.6%), pelvis (1.6%), and back (0.6%). Similar findings were described in a prospective study by Bennell et al. (1996) in which the tibia (46%), navicular (15%), and fibula (12%) were the most common stress fracture sites.

Women have been reported to sustain a disproportionately higher incidence of stress fractures than men. The relative risk of women in military populations undergoing identical training programs as their male counterparts has been reported to be as high as 10 times (Protzman & Griffis, 1977). However, in the athletic population, when either the number of injured athletes or the number of stress fractures per 1000 training hours were compared, men and women were found to be at equal risk (Tuan et al, 2004).

References

Evans, J.T., Guyver, P.M., Kassam, A.M. & Hublle, M.J. (2012) Displaced Femoral Neck Stress Fractures in Royal Marine Recruits – Management and Results of Operative Treatment. Journal of the Royal Naval Medical Service. 98(2), pp.3-5.

Tuan, K., Wu, S. & Sennet, B. (2004) Stress Fractures in Athletes: Risk Factors, Diagnosis and Management. Orthopedics. 27(6).

Matheson, G.O., Clement, D.B., McKenzie, D.C., Taunton, J.E., Lloyd-Smith, D.R. & MacIntyre, J.G. (1987) Stress Fractures in Athletes: A Study of 320 Cases. American Journal of Sports Medicine. 15, pp.46-58.

Callahan, L.R. (2000) Stress Fractures in Women. Clinical Sports Medicine. 19, pp.303-314.

Sallis, R.E. & Jones, K. (1991) Stress Factures in Ahletes: Hw to Spot this Underdiagnosed Injury. Postgraduate Medicine. 89, pp.185-188 & 191-192.

Bennell, K.L., Malcolm, S.A., Thomas, S.A., Wark, J.D. & Brukner, P.D. (1996) The Incidence and Distribution of Stress Fractures in Competitive Track and Field Athletes: A Twelve-month Prospective Study. American Jounral of Sports Medicine. 24, pp.211-217.

Protzman, R.R. & Griffis, C.G. (1977) Stress Fractures in Men and Women undergoing Military Training. Journal of Bone and Joint Surgery of American. 59, pp.825.

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