What is the initial management for an elderly patient with a compression fracture?

Initial Management of Vertebral Compression Fractures in Elderly Patients

The initial management of elderly patients with vertebral compression fractures should involve a multidisciplinary clinical approach with adequate pain relief, appropriate fluid management, and consideration for surgical intervention within 48 hours if there are neurological deficits or spinal instability. 1

Pain Management

• Appropriate pain management should be provided as soon as possible before starting diagnostic investigations 1
• Pain control options include:
  • Analgesics (acetaminophen, NSAIDs if not contraindicated) 2
  • Nerve blocks have been demonstrated to reduce acute pain in patients with fractures 1
  • Opioid medications may be necessary for severe pain but should be used cautiously due to side effects in elderly patients 2

Initial Assessment and Stabilization

• Systematic multidisciplinary comprehensive assessment should include investigations for common modifiable variables: 1
  • Malnutrition
  • Electrolyte or volume disturbances
  • Anemia
  • Cardiac or pulmonary diseases
  • Dementia and delirium control
• Preoperative investigations should include: 1
  • Chest X-ray
  • ECG
  • Full blood count
  • Clotting studies
  • Renal function
  • Assessment of cognitive baseline function

Treatment Approach Based on Clinical Presentation

• For stable compression fractures without neurological deficits: 2, 3

  • Conservative management is typically the first-line approach
  • Combination of medications, bracing, and physical therapy
  • Bed rest should be minimized as it leads to adverse outcomes including functional decline, bone density decrease (approximately 2% per week), and muscle strength decrease (1-3% per day) 1

• For compression fractures with neurological deficits or spinal instability: 4

  • Urgent surgical intervention is required
  • Corticosteroid therapy should be initiated
  • Surgery should be performed as soon as possible to prevent further neurological deterioration

Orthogeriatric Care

• Orthogeriatric comanagement should be provided to improve functional outcomes and reduce length of hospital stay and mortality 1
• The joint care model between geriatrician and orthopaedic surgeon on a dedicated orthogeriatric ward has shown: 1
  • Shortest time to surgery
  • Shortest length of inpatient stay
  • Lowest inpatient and 1-year mortality rates

Interventional Procedures

• Consider vertebral augmentation procedures (vertebroplasty or kyphoplasty) for patients who do not respond to initial conservative treatment 5, 6
• Compared to conservative treatment, percutaneous kyphoplasty (PKP) provides: 6
  • Rapid pain relief
  • Restoration of damaged vertebral body height
  • Correction of Cobb's angle
  • Improved quality of life

Complications of Immobilization

• Prolonged bed rest should be avoided due to significant adverse effects: 1
  • Bone density decreases approximately 2% per week
  • Muscle strength decreases 1-3% per day or 10-15% per week
  • Almost half of normal strength is lost within 3-5 weeks
  • Decreased endurance leading to fatigue and reduced patient motivation
  • Glucose intolerance
  • Increased risk of pressure ulcers and pneumonia 1

Prevention of Subsequent Fractures

• Identify and treat predisposing factors for osteoporosis 5
• Implement measures to prevent falls 5
• Consider bone density assessment and appropriate osteoporosis treatment 3