Working Diagnosis:
Non-traumatic complete femoral neck fracture with poor healing in an adolescent with the female athlete triad and genetic predisposition for osteoporosis.

Treatment:
Patient and parental education, dietitian referral, sports psychology referral calcium and vitamin D supplementation, bone stimulator and rehabilitation.

Outcome:
In October 2010, she progressed to full weight-bearing and was pain free with a mildly antalgic gait. In therapy she continues to work on motion and is beginning to incorporate strengthening. She has been eumenorrheic since August 2010. It has been recommended that she have an orthopedic surgery second opinion regarding possible surgical revision due to the varus angulation on her recent radiographs.

Author's Comments:
The metabolic consequences of a negative energy balance is the same whether or not there is a frank eating disorder present or if it is an inadvertent negative energy balance. This athlete met all the criteria for the female athlete triad: 1. Osteoporosis given her low BMD per revised ACSM criteria and the nature of her fracture 2. Secondary amenorrhea- Functional hypothalamic amenorrhea 3. Negative Energy Balance.

References:
1. Bailie DS, Lamprecht DE. Bilateral femoral neck stress fractures in an adolescent male runner. A case report. Am J Sports Med. 2001;29(6):811-3.
2. Caronia LM, Martin C, Welt CK et al. A genetic basis for functional hypothalamic amenorrhea. N Engl J Med. 2011 Jan 20;364(3):215-25.
3. Cichy B, Roche SJ, Wozniak A. Atypical femoral neck stress fracture in a marathon runner: a case report and literature review. Ir J Med Sci. 2010 Oct 8.
4. Committee to review dietary reference intakes for vitamin D and calcium. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: Institute of Medicine; 2010.
5. “Overuse Injuries.� DeLee and Drez's Orthopaedic Sports Medicine, 3rd ed Saunders Elselvier, 2010.
6. Fullerton LR, Snowdy HA: Femoral neck stress fractures. Am J Sports Med. 16:365, 1988.
7. Harrast MA, Colonno D. Stress fractures in runners. Clin Sports Med. 2010;29(3):399-416.
8. The International Society for Clinical Densitometry. 2007 Pediatric Official Positions of the International Society for Clinical Densitometry; 2007. Accessed April 24, 2011: (http://www.iscd.org/Visitors/positions/OfficialPositionsText.cfm).
9. Johansson C, EKenman I, Tornkvist H et al. Stress fractures of the femoral neck in athletes. The consequence of a delay in diagnosis. Am J Sports Med. 1990; 18(5):524-8.
10. Kerr PS, Johnson DP. Displaced femoral neck stress fracture in a marathon runner. Injury. 1995; 26(7):491-3.
11. Lee CH, Huang GS, Chao KH et al. Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases. Arch Orthop Trauma Surg. 2003; 123(10):527-33.
12. Nattiv A, Loucks AB, Manore MM et al. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 2007 Oct;39(10):1867-82.
13. Ralston SH. Genetics of Osteoporosis. Ann N Y Acad Sci. 2010 Mar;1192:181-9.
14. Ralston SH, Uitterlinden AG. Genetics of Osteoporosis. Endocr Rev. 2010 Oct;31(5):629-62.
15. St Pierre P, Staheli LT, Smith JB et al. Femoral neck stress fractures in children and adolescents. J Pediatr Orthop. 1995;15(4):470-3.
16. Thompson RA, Sherman RT. Eating Disorders in Sport. New York: Routledge, 2010.

Return To The Case Studies List.