Orthopedics Book

Fracture Management

  • Vertebral Compression Fracture

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Vertebral Compression FractureAka: Vertebral Crush Fracture

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  1. See Also
    1. Osteoporosis
  2. Causes
    1. Osteoporosis (700,000 related U.S. Fractures per year)
    2. Chronic use of Systemic Corticosteroids
    3. Cancer with lytic bony metastases
  3. Risk Factors
    1. See Osteoporosis
    2. Prior vertebral Fracture confers 5 fold increased risk
  4. Symptoms
    1. Sudden onset of severe pain
    2. Follows trauma
      1. Occurs with minor stress in severe Osteoporosis
        1. Sneezing
        2. Transferring out of bathtub
        3. Rolling over in bed (30% of Fractures)
      2. Occurs with greater stress in moderate Osteoporosis
        1. Fall out of a chair
      3. Higher energy injury can cause compression in anyone
        1. Motor vehicle accident
        2. Fall from height
    3. Most common sites (multiple levels often involved)
      1. Thoracic spine: T] to T12
      2. Lumbar spine: L1 and L4
    4. Radiation of pain across back and into trunk
      1. Rarely radiates into legs
    5. Paraspinous muscle Fatigue related pain (prolonged)
  5. Signs
    1. Loss of total height measurement
      1. Women: >4 cm height loss since age 25 years
      2. Men: >6 cm height loss since age 25 years
    2. Thoracic kyphosis (from anterior wedge Fractures)
    3. Lumbar lordosis (corrects for kyphosis)
    4. Tenderness over area of acute Fracture
  6. Complications
    1. Constipation, ileus, or Bowel Obstruction
    2. Loss of mobility (Deep Vein Thrombosis risk)
    3. Impaired lung function (Atelectasis and Pneumonia risk)
    4. Chronic Pain
  7. Differential Diagnosis
    1. Spinal Osteomyelitis
  8. Imaging
    1. Spinal XRay
      1. Loss of vertebral height of 20% or 4 mm from baseline
      2. Grading of changes
        1. End-plate deformity
        2. Anterior wedge Fracture
        3. Complete collapse of vertebrae (burst Fracture)
    2. CT Spine Indications
      1. Characterize suspected Fracture site
      2. Suspected Lumbar Spinal Stenosis
    3. MRI Spine Indications
      1. Suspected Lumbar Spinal Stenosis
      2. Significant secondary neurologic sequelae
      3. Differentiate acute versus old compression Fracture
      4. Pathologic Fracture (malignancy) suspected
        1. No Trauma History in under age 55 years
    4. Bone scan indications
      1. Atypical presentation with several levels involved
      2. Sacral insufficiency Fracture (H-pattern at sacrum)
  9. Management: Stable Compression Fractures
    1. Confirm that Fracture site is stable (typical)
    2. Symptomatic back pain management
    3. Physical therapy
      1. Encourage upper body Exercises and walking
      2. Avoid flexion Exercises (e.g. crunches)
        1. Increases risk of additional compression Fractures
    4. External back-bracing (Maximum of 4 weeks)
      1. Use for comfort and pain control
    5. Calcitonin (Miacalcin) nasal spray
      1. Silverman (2002) Osteoporos Int 13:858
  10. Management: Refractory severe pain or >6 weeks of pain
    1. Percutaneous Vertebroplasty
    2. Kyphoplasty (Restores vertebral height)
  11. Prevention
    1. Osteoporosis Management
    2. Bone loading Exercise program (e.g. walking)
    3. Muscle strengthening
  12. Course
    1. Improvement usually occurs over 6 to 12 week period
  13. References
    1. Raisz in Wilson (1998) Endocrinology, p. 1223-4
    2. Old (2004) Am Fam Physician 69:111
    3. Predey (2002) Am Fam Physician 66(4):611

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