a 53-year - old lady presented to our outpatient department with a pain on the right hip and limping gait .
her gait was antalgic , with moderate decrease in weight bearing on the right lower extremity .
on the physical examination , mild swelling and localized tenderness were found at the greater trochanteric area .
the range of motion ( rom ) was symmetrical and within normal limits in the lower extremities , but the patient reported hip pain on either abduction or internal rotation of right hip joint .
anteroposterior and lateral radiographs showed transverse fracture below the greater trochanter and above the lessor trochanter ( fig .
1 ) . for differential diagnosis we performed magnetic resonance imaging ( mri ) and tc-99 m bone scan . mri revealed the intertrochanteric fracture with surrounding marrow edema ( fig .
2 ) , whole body bone scan showed a focal hot uptake on the fracture site ( fig .
3 ) . there was no evidence of metabolic and endocrinologic disorders on laboratory tests .
she had a past history of l4 - 5 fusion due to spondylolisthesis , but there was no history of any other comorbidities .
she was a window cleaner working at single - story buildings , not at high floors of skyscraper .
she worked three days a week , and the frequency of jumping ups and downs around the window frames was ten to twelve times a day .
she recalled that the onset of her symptoms was approximately three weeks ago , which was two years after the initiation of her working .
she denied any type of trauma , and she described her primary symptom as a dull ache in the right hip .
approximately two weeks after the onset of her symptoms , she experienced severe pain after work and difficulty with normal ambulation .
she encountered menopause four years ago , but the bone mineral density showed no osteoporosis .
dual energy x - ray absorptiometry showed a lumbar spine t score of + 0.2 and a contralateral trochanter t score of 0.9 .
body mass index ( weight/ height ) was 22.5 kg / m ( 52/1.52 ) .
we decided a fixation of the fracture because the trochanteric fracture may lead to adverse consequence such as displacement and prolonged morbidity .
, she was permitted to ambulate with crutches and touch - down weight bearing on the right extremity . following discharge
she was referred for out patient physical therapy consisting of rom exercise and partial weight bearing ambulation with crutches .
the patient was also instructed in isometric exercises for the gluteal , quadriceps , hamstring , and hip abductor muscles .
six weeks after surgery , the patient was ambulatory without an assistive device or weight bearing restriction .
anteroposterior and lateral radiographs obtained two months after surgery ( about three months after onset of symptom ) revealed bony union with good alignment ( fig .
the last follow - up visit one year after surgery , the patient was fully back to work without pain or discomfort in right lower extremity .
femoral stress fractures are rare , representing only about 5% of all stress fractures2345678 ) .
volpin reported that most of femoral stress fractures were located in diaphysis4 ) , and fewer than 10% of stress injuries involved the femoral neck .
however , a recent study have suggested that three most common sites were the femoral neck ( 50% ) , the condylar area ( 24% ) , and the proximal shaft ( 18% ) in finnish military conscripts1 ) .
other sites were the supracondylar area , middle and distal third of the shaft and femoral head .
. however , stress fractures in labors are very rare5 ) . to our knowledge ,
our case was the first of trochanteric stress fracture , happened by labor - related stresses .
the differential diagnosis for hip pain is wide and pathological fractures ( congenital defects , general systemic disease , metastatic bone tumors ) , pseudo - fractures ( paget 's disease , osteomalacia , rickets ) , osteitis due to tuberculosis or syphilis , simple fracture due to violence , and osteomyelitis must be distinguished3 ) .
we diagnosed the fracture first by plain radiographs , but ordered mri and bone scan for the confirmation and ruling out other pathologic conditions .
mri revealed the fracture with surrounding edema and bone scan showed a focal hot uptake on the trochanteric area .
. the risk factors that can cause stress fractures include excessive use , nutritional deficiencies , and endocrine disorders .
in addition , stress fractures may arise from long standing rheumatoid arthritis , osteoporosis , steroid therapy , joint stiffness , or the correction of angular deformity9 ) . in current case
at junction of the proximal and middle thirds of the femoral shaft lies the insertion of adductor muscles , which may cause proximal femoral shaft fracture1 ) .
however , authors suggest that the trochanteric stress fracture might have been caused by strong and repetitive stresses on trochanteric region at the insertion point of abductor muscles , and focal bending stresses beyond the ability of the bone to tolerate have resulted in fracture .
because the patient had a difficulty on weight bearing and the fracture had a risk of displacement , we performed internal fixation with hip nailing .
for the purpose of early ambulation and fast recovery to work , internal fixation should be considered as initial treatment for patient with trochanteric stress fracture , even for non - displaced fracture10 ) .
 stress fractures may occur at various sites in the femur including the head , neck , shaft , supracondylar and condylar regions . to the best of our knowledge , stress fracture occurring in the trochanteric region has not been previously reported . 
 we report here a case of trochanteric stress fracture in a 53-year - old female window cleaner treated with hip nailing without adverse consequences 
 . careful consideration of this entity is needed when evaluating patients who have repetitive jumping up and down . 
CASE REPORT
DISCUSSION