Grade 4 Distal Femur Stress Fracture in a Long-Distance Hiker on the Appalachian Trail

Abstract

Although stress injuries are a common occurrence in sports medicine clinics, a distal femur stress fracture is less so. Early detection can result in a favorable prognosis and may prevent the need for surgical intervention. A misdiagnosis resulting in delay of care can result in significant complications. This case report documents a rare distal femur stress fracture in a long-distance hiker. A 35-y-old male presented to an orthopedic clinic in Pennsylvania with left knee pain after completing 1423 km (884 mi) of the Appalachian trail over a 4-mo period. He was attempting a thru-hike, a specialized type of backpacking focused on completing a trail from end-to-end. Thru-hiking of this trail involves backpacking between Georgia and Maine, covering about 3540 km (2200 mi) with approximately 141,580 m (464,500 ft) of gain/ loss in elevation. His pain began 2 mo into his hike when he noted medial sided left knee discomfort. Over the following 2 mo he sought treatment at 2 different locations along the trail with etiology undetermined. Upon evaluation in Pennsylvania, history and physical exam were suggestive of a stress fracture. Radiologic studies confirmed a closed nondisplaced nonangulated grade 4 transverse fracture of the shaft of the distal left femur. The patient was instructed to terminate his hike immediately and he was placed on nonweight bearing status. This case illustrates the importance of considering a distal femur stress fracture for the differential diagnosis of persistent knee pain in a long-distance hiker.

Medial femoral Condyle Stress Fracture: A Case Report

“…Stress fracture accounts for 20% of cases in a sports medicine clinic [ 6 ]. They are commonly encountered when a normal bone is undergoing repetitive stress or when a weakened bone undergoing physiological loading.…”

“…The femur accounts for 6-7% of cases of stress fracture usually occurring in the neck region. The incidence of a stress fracture in the distal femur region is unknown due to the unusual site of presentation [ 6 ]. Our case had no military and athletic background, and neither had any abnormal bone metabolic studies which make our case a rare of rare entity, so reporting such an interesting case becomes an essentiality.…”

“…The initial imaging modality to start with for a suspected stress fracture is a plain radiograph, which has a sensitivity of only 10% in the first 3 weeks after the symptoms [ 6 ]. In our case too, the plain radiographs were normal and showed no signs of a stress fracture of the medial condyle of the femur.…”