What is the initial management for patients presenting with compression fractures?

Initial Management of Compression Fractures

Initial management of vertebral compression fractures should include calcitonin for 4 weeks in acute cases (0-5 days after onset), appropriate analgesics based on pain severity, and limited activity while avoiding prolonged bed rest. 1

Diagnostic Approach

• Confirm diagnosis through:
  • Clinical history focusing on pain characteristics (acute onset, worsening with movement)
  • Imaging: Plain radiographs initially, with MRI or CT if malignancy is suspected or neurological deficits are present 1, 2
  • MRI helps determine if fracture is acute vs chronic 2

Phase-Based Management Algorithm

Acute Phase (0-5 days)

1. Pain Management:

   • Mild pain: Acetaminophen or NSAIDs
   • Moderate to severe pain: Short-term opioids may be considered 1
   • Calcitonin for 4 weeks (provides analgesic effect) 1

2. Activity Modification:

   • Limited activity but avoid prolonged bed rest 1
   • Consider bracing for external support (though evidence is inconclusive) 1

Subacute Phase (1-4 weeks)

1. Medical Management:

   • Start bisphosphonates to prevent additional fractures
   • Calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 1
   • Continue appropriate analgesics

2. Consider Bracing:

   • May provide external support and limit painful movements
   • Selection should consider specific type of brace, patient age, and fracture level 1

3. Physical Therapy:

   • Begin structured physical therapy targeting lumbar stabilization 1

Chronic Phase (>4 weeks)

1. Continue Medical Management:

   • Maintain bisphosphonate therapy
   • Continue calcium and vitamin D supplementation 1

2. Rehabilitation:

   • Gradual increase in physical activity
   • Targeted exercise program
   • Balance training for long-term benefit 1

3. For Refractory Cases:

   • Consider L2 nerve root block for L3 or L4 compression fractures 1
   • Vertebral augmentation only if conservative management fails (though vertebroplasty is not recommended based on high-quality evidence) 1, 3

Important Considerations and Pitfalls

Evidence-Based Interventions

• Strong evidence against vertebroplasty: Two level I studies showed no statistically significant difference between vertebroplasty and sham procedure for pain relief or function 3, 1
• Inconclusive evidence for bracing: Limited data on effectiveness, though it may provide symptomatic relief 3, 1
• Inconclusive evidence for exercise programs: Some studies suggest potential benefits in symptom improvement at 6 and 12 months 3, 1

Red Flags Requiring Urgent Attention

• Neurological deficits suggesting spinal cord compression
• Suspected malignant spinal cord compression requires:
  • Immediate high-dose dexamethasone
  • Urgent MRI
  • Neurosurgical consultation 1

Common Pitfalls to Avoid

1. Prolonged bed rest: Can lead to deconditioning, muscle atrophy, and increased risk of complications 1, 4
2. Delayed diagnosis of malignant causes: Always consider pathologic fractures in patients with risk factors or atypical presentation 2
3. Overreliance on vertebroplasty: Despite widespread use, high-quality evidence does not support its effectiveness 3, 1
4. Neglecting underlying osteoporosis treatment: Management must address the root cause to prevent future fractures 1, 5

By following this structured approach based on the phase of the fracture, clinicians can provide appropriate care while minimizing complications and optimizing outcomes for patients with vertebral compression fractures.