Case Author(s): David A. Hillier, M.D., Ph.D. and Henry D. Royal, M.D. , 7/1/99 . Rating: #D2, #Q3

Diagnosis: Stress fracture of femur

Brief history:

19 year-old man with right hip pain.


Bone scintigraphy

View main image(bs) in a separate image viewer

View second image(xr). Right femur plain films

Full history/Diagnosis is available below

Diagnosis: Stress fracture of femur

Full history:

19 year-old man with right hip pain. He is a runner on his college track team. He noted hip pain one month ago while running which has improved with decreased physical activity.


20 mCi MDP, IV


1. Bone scintigraphy:

- Ovoid focal uptake at medial aspect of proximal right femoral metadiaphysis.

2. Right femur:

- Periosteal formation correlating with scintigraphic abnormality.


Stress fracture occurs in normal bone that undergoes abnormal stress. Insufficiency fractures occur with normal stress in bones that are weakened or osteoporotic.

Bone scintigraphy becomes positive at the same time or sooner than plain films and has a low false-negative rate. The most common sites of stress fracture are the femoral neck and tibia. Less commonly, the femoral diaphysis may be involved.


Burr D, et al. Experimental stress fractures of the tibia. J of Bone & Joint Surg. 72-B, 370-375. 1990.

Donohoe K. Selected topics in orthopedic nuclear medicine. Orthop clin N Am. 29, 85-101. 1998.

Holder L. Bone scintigraphy in skeletal trauma. Rad clin N Am. 31, 739-781. 1993.

Lesho E. Can tuning forks replace bone scans for identification of tibial stress fractures? Milit Med. 162, 802-803.

Milgrom C, et al. The long-term followup of soldiers with stress fractures. 13, 398-400. 1985.

Wilcox J, et al. Bone scanning in the evaluation of exercise-related stress injuries. Rad. 123, 699-703. 1977.

Zwas ST, et al. Interpretation and classification of bone scintigraphic findings in stress fractures. J Nucl Med. 28, 452-457. 1987.

Differential Diagnosis List

The differential diagnosis for the ovoid cortical uptake in this location in a weight-bearing bone includes stress fracture, osteoid osteoma, metastatic lesion (the lack of multiple lesions mitigates against this). Given the history of running on the college track team, temporally coinciding with the onset of pain, this is likely to represent stress fracture.

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Skeletal System, Category:Effect of Trauma)

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Case number: bs106

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