What are the next steps for a 76-year-old male with an acute compression fracture?

Management of Acute Compression Fracture in a 76-Year-Old Male

For a 76-year-old male with an acute vertebral compression fracture, the next steps should include appropriate pain management, consideration of vertebral augmentation after 6 weeks of failed conservative therapy, and implementation of secondary fracture prevention strategies.

Initial Assessment and Diagnosis Confirmation

• Confirm the fracture is acute through:
  • Physical examination: Check for point tenderness at the spinous process of the fractured vertebra 1
  • Consider specialized clinical tests:
    • Closed-fist percussion sign (sensitivity 87.5%, specificity 90%) 2
    • Supine sign - assess pain when patient lies supine (sensitivity 81.25%, specificity 93.33%) 2
  • MRI is the preferred imaging modality to confirm acuity of fracture and rule out malignancy 1, 3

Immediate Pain Management

• Begin with analgesics:
  • Regular administration of paracetamol as the foundation of pain therapy
  • Cautious use of opioids with reduced dosing (typically half the standard dose) in elderly patients
  • Avoid codeine due to side effects in older patients 4
• Consider calcitonin for 4 weeks if presenting within 5 days of injury (Level II evidence) 1

Conservative Management (First 6 Weeks)

• Limited bed rest (avoid prolonged immobilization)
• Bracing may be considered, though evidence is inconclusive 1
• Early mobilization as tolerated to prevent complications of immobility
• Physical therapy focused on:
  • Core strengthening
  • Proper body mechanics
  • Fall prevention strategies 5

Indications for Vertebral Augmentation

Consider vertebral augmentation (vertebroplasty or kyphoplasty) if after 6 weeks of conservative management:

1. Pain persists preventing ambulation or physical therapy despite appropriate analgesics
2. Significant side effects from analgesics (confusion, sedation, severe constipation)
3. Failure of medical therapy for minimum of 6 weeks 1

Contraindications to Vertebral Augmentation

• Absolute contraindications:
  • Active systemic or spinal infection
  • Uncorrectable bleeding diathesis
  • Insufficient cardiopulmonary health for sedation
  • Known allergy to the polymer used 1
• Relative contraindications:
  • Significant spinal canal stenosis
  • Compressive myelopathy from retropulsed fragment
  • Radiculopathy exceeding local vertebral pain 1

Secondary Fracture Prevention

• Calcium and vitamin D supplementation:
  • Calcium 1000-1200 mg/day
  • Vitamin D 800 IU/day 1
• Initiate osteoporosis assessment:
  • DXA scan for bone mineral density testing
  • Laboratory evaluation for secondary causes of osteoporosis 1
• Consider pharmacologic therapy:
  • First-line: Oral bisphosphonates (alendronate or risedronate)
  • For patients with oral intolerance: Zoledronic acid (IV) or denosumab (subcutaneous)
  • For severe osteoporosis: Consider teriparatide 1, 6
• Fall prevention strategies:
  • Home safety assessment
  • Balance training
  • Strength exercises 1

Follow-up Care

• Regular assessment of pain control and functional status
• Monitor for complications:
  • Progressive vertebral collapse
  • Adjacent vertebral fractures
  • Neurological compromise 3
• Ensure adherence to osteoporosis medications
• Continued physical therapy for strengthening and balance

Important Considerations

• Vertebral augmentation procedures have shown faster improvement in pain scores and functional ability compared to conservative management in some studies 7
• Major complications from vertebral augmentation occur in less than 1% of patients treated for osteoporotic compression fractures 1
• Systematic follow-up is crucial for medication adherence, which can be substantially higher (up to 90%) in patients enrolled in fracture liaison services 1

Remember that early intervention and a comprehensive approach to both acute fracture management and secondary prevention are essential to reduce morbidity, mortality, and improve quality of life in elderly patients with vertebral compression fractures.