stress fractures occur in individuals in whom repetitive strenuous muscle and tendon force act on bone ; that have not adapted to such forces . under a constant load , osteoclast resorption and osteoblastic reconstruction of bone
are in equilibrium , resulting in normal remodeling . if loading increases , additional bone resorption occurs
. increased osteoclastic activity at sites of stress may cause local weakening and predispose to micro damage .
a 30-year - old man presented with right thigh pain for 3 days without any history of significant trauma .
he was a military recruit with history of running 5 miles a day for last 12 years and was running 20 miles a day for last 5 days before he developed pain .
here we have reported a case of stress fracture of proximal femur in intertrochanteric region which to our knowledge has not been reported in the literature so far .
this fracture is important to recognize early as there are high chances of displacement resulting in increased risk of complications .
we suggest immediate anatomical reduction and stable internal fixation to prevent complications and early mobilization to decrease the morbidity .
stress fractures occur in individuals in whom repetitive strenuous muscle and tendon force act on bone ; that have not adapted to such forces.[1 - 3 ] stress fractures can be subdivided into fatigue fractures , caused when normal bone is exposed to repeated abnormal stress , and insufficiency fractures , where normal stress is applied to abnormal bone . under a constant load , osteoclast resorption and osteoblastic reconstruction of bone
are in equilibrium , resulting in normal remodelling . if loading increases , additional bone resorption occurs
. increased osteoclastic activity at sites of stress may cause local weakening and predispose to micro damage .
although stress fractures can arise at any site , the most common locations are postero - medial tibia , particularly in runners ; metatarsals in runners , dancers , and military recruits ; iliopubic and ischiopubic rami in military recruits , gymnasts , dancers , and soccer players ; and femur in crosscountry runners .
stress fractures of the femur are usually seen in osteoporotic elderly people , but in healthy young athletes they are less common .
fractures localized to the superior surface of neck of femur are termed tension fractures , and those localized to the inferior surface , compression fractures . to our knowledge
, the literature contains no reports of stress fracture of proximal femur in intertrochanteric region . here , we describe a case of stress fracture of the proximal femur in intertrochanteric region in a male military recruit .
the patient was informed that data concerning the case would be submitted for publication , and he consented .
a 30-year - old man presented with right thigh pain for 3 days without any history of significant trauma .
he was a military recruit with history of running 5 miles a day for last 12 years and was running 20 miles a day for last 5 days before he developed pain .
all blood investigations including serum levels of calcium , phosphorus , pth and creatinine were normal except for low 25-hydroxy vitamin d3 levels ( 22.4 ng / ml ) .
reports of 99m - technetium mdp bone scan , magnetic resonance imaging ( mri ) and computed tomography ( ct ) were consistent with stress fracture with no other pathology .
patient was managed by closed reduction and internal fixation with dynamic hip screw with anti - rotation screw .
initially patient was molilised toe touch walking with cruch support with regular follow up and at the present time patient is walking full weight wearing , no pain , without support and performing his daily routine activities and joined his duties as well .
the literature renders different opinions and data with regard to stress fractures and the structural integrity of bones .
a number of authors feel that wolff 's law is applicable with stress fractures in that the bone is attempting to adapt to the ongoing stresses .
it appears that bone resorption with accelerated repetitive stress occurs at a greater rate than bone deposition .
the end result is a stress fracture from repetitive , cumulative stress exceeding the structural strength of the bone .
histologically , as humans mature from adolescence , the bone in the femoral neck undergoes internal remodeling of circumferential lamellar bone to adult osteonal bone .
experimentally , the greater the percentage of osteones with lamellar bone , the greater the resistance to failure with repeated loading .
fractures appear to be related to the rate of loading , if the rate of loading exceeds the rate of there modeling of bony buildup , then a fracture may occur with stress .
the femoral neck is subjected to loading forces several times body weight and with stands considerable tensile and compressive forces .
it is important to consider these two distinct forces separately because they lead to different injury types and outcomes .
tensile forces occur at the superior aspect of the femoral neck , where as compressive forces occur at the inferior aspect .  
[ 12 - 14 ] other biomechanical factors , such as leg length inequality , coxavara , and pescavus , may also be important in the development of compressive and tensile injuries at the femoral neck .
femoral neck stress fracture has many associated complications such as nonunion , malunion , osteonecrosis , and arthritic changes .  
many authors suggest that tension side femoral neck stress fractures require internal fixation because of potential instability and high rate of complications ; however , there are reports of successful conservative management for non - displaced tension side fractures   compression side fractures are generally treated conservatively with a period of rest followed by gradual return to activity and exercises .
femoral neck stress fractures treated conservatively should have frequent radiographic monitoring for progression given the high incidence .
return to running is considered when full weight bearing is asymptomatic , there is no tenderness to palpation on physical examination , and imaging studies are consistent with healed fracture .
literature is not available on stress fracture in pertrochanteric region so biomechanics related to it is not clear .
the pertrochanteric region is quite variable in its combination of cortical and cancellous bone structure .
the well - vascularized pertrochanteric region is dependent on the structural integrity of a laminated cancellous bone arcade from the femoral head and epiphyseal scar , around ward 's triangle to the lesser trochanter , where the solid nature of the structure changes to a tubular construct with the origin of the femoral medullary canal ; the strong plate of bone posteriorly is named the calcar femorale .
this is the region most affected with the posteromedial fracture comminution leaving only the anteromedial cortex potentially stable .
the main structural attachments to the proximal femur include the hip capsule and the musculotendinous junctions of the gluteus medius and minimus ( greater trochanter ) , iliopsoas ( lesser trochanter ) , pirifomis and short external rotators ( posterior trochanteric region from the greater trochanteric region to the lesser trochanter ) , the oblique head of the rectus femoris ( anterior capsule ) , and the vastus lateralis ( lateral femur distal to the greater trochanter ) .
the hip capsule is especially important in reduction of pertrochanteric fractures and its continuity with the distal fragment is the soft tissue attachment on which a stable reduction is possible . with capsular disruption ,
the displacement of the fracture fragments is dependent on the musculotendinous attachment to the respective fragments .
the greater trochanter is abducted and externally rotated by the gluteus medius and short external rotators , the shaft is displaced posteriorly and medially by the adductors and hamstrings .
lambotte described the four components of surgical treatment of fractures at the turn of the twentieth century , and they are as applicable today as then .  
the first is exposure of the fracture , which today means visualization of the fracture deformity , and the safest approach to ensure reduction and placement of the implant in the correct position .
the second is reduction of the fracture , which is critical to the stability and functional recovery of the patient .
inadequate reduction is the major preventable etiology for lost reduction and implant failure in pertrochanteric fractures .
the third step is provisional fixation in an anatomically reduced position ; this is frequently the most neglected step in hip fracture surgery .
this involves the reduction of the fracture and then maintenance of the fracture with either provisional kirschner pins and/or clamps to hold the fracture in position while the bone is prepared for the definitive implant .
the last step is definitive fixation , which should maintain the reduced fracture in an acceptable anatomic and functionally correct position until fracture healing is complete .
[ lambotte principal of fracture management was basically given for traumatic fractures that is still followed for such injury .
it means lambotte principal of fracture management can be applied for fracture caused by severe trauma and also for stress fracture .
here we have reported a case of stress fracture of proximal femur in intertrochanteric region which to our knowledge has not been reported in the literature so far .
this fracture is important to recognize early as there are high chances of displacement resulting in increased risk of complications .
we suggest immediate anatomical reduction and stable internal fixation to decrease the morbidity and prevent complications .
so any patient particularly military recruit if presented with mild pain in groin during activity and relieved by rest must be suspected for insufficiency fracture .
if on plane radiography lesion is not visible , go with the most common investigation i.e. mri .
if the fracture is displaced , it should be fixed to prevent complications and early mobilization to decrease morbidity of patient .
 introduction : stress fractures occur in individuals in whom repetitive strenuous muscle and tendon force act on bone ; that have not adapted to such forces . under a constant load , osteoclast resorption and osteoblastic reconstruction of bone 
 are in equilibrium , resulting in normal remodeling . if loading increases , additional bone resorption occurs 
 . increased osteoclastic activity at sites of stress may cause local weakening and predispose to micro damage . 
 if allowed to progress , such micro fractures may progress to complete fractures.case report : a 30-year - old man presented with right thigh pain for 3 days without any history of significant trauma . 
 he was a military recruit with history of running 5 miles a day for last 12 years and was running 20 miles a day for last 5 days before he developed pain . 
 examination revealed pain to palpation along the proximal medial and lateral right thigh . 
 range of motion was painful and limited . 
 radiograph of right hip showed fracture line in intertrochanteric region of femur.conclusion:here we have reported a case of stress fracture of proximal femur in intertrochanteric region which to our knowledge has not been reported in the literature so far . 
 this fracture is important to recognize early as there are high chances of displacement resulting in increased risk of complications . 
 we suggest immediate anatomical reduction and stable internal fixation to prevent complications and early mobilization to decrease the morbidity . 
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Case Report:
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Introduction
Case Report
Discussion
Conclusion