Compression Fracture

Fragility fracture of the spine which rarely causes neurologic deficits and can
often be treated nonoperatively, although cement augmentation may potentially
improve pain relief and functional improvement.

Overview

• Most common fragility fracture

• Failure of anterior column from anterior (most common) or lateral flexion
• Associated with significant 2-year mortality

° Rule out underlying metastatic etiology

° Medical management to optimize bone quality
• Expected full resolution of pain and return to previous function
• Increased kyphosis from multiple adjacent fractures can compromise pulmonary
function

History

• Did you have any preceding trauma?

• Have you ever had this type of pain before in your spine?
• Have you ever been diagnosed with osteoporosis?
• Do you have history or family history of cancer, or recent fevers, chills, or weight
loss?
• Do you have any weakness, numbness, or tingling?

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M.C. Makhni et al. (eds.), Orthopedic Emergencies,
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Physical Exam

• Assess for focal sites of tenderness along entire spine

• Complete Neurologic Exam (Appendix A)

Imaging

• XRs entire spine (Fig. 1)

° Loss of anterior column vertebral height and maintained posterior column

° Assess for other sites of compression fractures *IMPORTANT*
° Evaluate if local kyphosis (especially if multiple compression fractures)
° Examine for possible lesions
• CT/MRI indicated if: neurologic deficit, lesions detected, insufficient plain films
to rule out middle or posterior column compromise, to assess acuity of fractures,
to diagnose occult fractures

Fig. 1 Compression fractures

Compression Fracture 73

Classification

Stable—most common
Unstable—>50 % loss of vertebral height
>20° angulation
Multiple adjacent fractures
Disruption of middle/posterior columns (burst, chance fracture)

Treatment Plan

Nonoperative

• Early ambulation with pain control

• Extension orthosis—unclear benefit, no Level 1 or 2 evidence to support
• Serial imaging for 3 months to confirm no progression of fracture
• Medical management of osteoporosis

° Consider bisphosphonates
° Consider calcitonin for 1 month after injury

Surgery

• Kyphoplasty (expansion of vertebral body followed by cement augmentation)

• Vertebroplasty (injection of cement into vertebral body in situ)
• 2010 AAOS Guideline against vertebroplasty-unclear benefit of kyphoplasty
• Several prospective randomized trials since then

° Most suggest improved pain relief and functional improvement with cement
augmentation
° Potential benefits up to 2 years
• Relative Indications

° Pathologic fractures
° Persistent pain >3–6 weeks
° Patients hospitalized due to pain
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References

Esses SI, McGuire R, Jenkins J, Finkelstein J, Woodard E, Watters WC, et al. The treatment of symp-
tomatic osteoporotic spinal compression fractures. J Am Acad Orthop Surg. 2011;19(3):176–82.
Hazel WA, Jones RA, Morrey BF, Stauffer RN. Vertebral fractures without neurologic deficit. A
long-term follow-up study. Bone Joint Surg Am. 1988;70(9):1319–21.
Savage JW, Schroeder GD, Anderson PA. Vertebroplasty and kyphoplasty for the treatment of
osteoporotic vertebral compression fractures. J Am Acad Orthop Surg. 2014;22(10):653–64.
The Treatment of Symptomatic Osteoporotic Spinal Compression Fractures Guideline and
Evidence Report. AAOS. 2010.