Presentation
Leg and hip pain bilaterally, left greater than right
Patient Data
There are focal areas of cortical thickening along the lateral surface of the proximal third of the bilateral femoral diaphyses. On the right there is one area showing this change, but on the left there are at least two (see arrows on subsequent slide). Also, subjacent to these areas, there is subtle endosteal sclerosis.
The stress (insufficiency) fractures are indicated by arrows.
Case Discussion
The lateral aspect of the femurs are under tension, while the medial sides are more affected by compressive forces. Tension-sided stress fractures are more concerning because normal biomechanical forces do not facilitate apposition. Also, it is strange to get enough chronic stress on the distractive side of a bone to cause a stress fracture, as stress fractures usually occur at critical sites of chronic compressive stress. Because of this, an underlying etiology should be sought, as this is suggestive of an insufficiency type of stress fracture (vs overuse). Bisphosphonate therapy has a known association with these atypical stress-fracture patterns, and should be a primary consideration in elderly female patients.
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