What is the treatment for a chronic wedge fracture, especially in the spine?

Treatment for Chronic Wedge Fracture in the Spine

For chronic wedge fractures in the spine, medical management is the first-line approach, including calcium and vitamin D supplementation, pain management, and bisphosphonates to treat underlying osteoporosis, while vertebral augmentation procedures may be considered for patients with persistent pain despite conservative management. 1

Initial Medical Management

• Pharmacological management forms the cornerstone of treatment for chronic vertebral compression fractures, including calcium and vitamin D supplementation as baseline treatment for underlying osteoporosis 1
• Bisphosphonates should be considered first-line therapy for treating the underlying osteoporosis, which may resolve bone pain while improving vertebral bone mineral density 1
• Calcitonin (200 IU) is recommended for the first 4 weeks following fracture onset to manage pain, with evidence showing clinically important pain reduction at 1-4 weeks 2
• For patients with refractory bone pain or worsening bone mineral density despite bisphosphonate therapy, anti-RANKL monoclonal antibodies (e.g., denosumab) can be considered as second-line therapy 1
• Ibandronate and strontium ranelate are options to prevent additional symptomatic fractures in patients with existing osteoporotic spinal compression fractures 2

Pain Management Approach

• Targeted analgesia tailored to individual needs is often required in both acute and chronic phases following vertebral fracture 3
• For patients with chronic pain from wedge fractures at L3 or L4 levels, L2 nerve root blocks may be considered as a treatment option 2
• Medical management with analgesics remains important when interventional procedures are contraindicated or not preferred 1
• Back pain from chronic vertebral fractures typically diminishes in severity after a few weeks but may remain intense for 2-3 months 4

Interventional Procedures

• Vertebral augmentation procedures (vertebroplasty or kyphoplasty) may be considered for patients with persistent pain despite 3 months of conservative management 1, 5
• The American Academy of Orthopaedic Surgeons (AAOS) recommends against vertebroplasty for osteoporotic spinal compression fractures, as level I studies show no statistically significant difference between vertebroplasty and sham procedures in pain reduction 2
• Kyphoplasty is considered an option for treating symptomatic fractures in patients who are neurologically intact, with some evidence suggesting it may provide better correction of spinal deformity and vertebral height 2, 1
• Factors associated with better pain relief after vertebroplasty include:
  • Younger age (under 60 years)
  • End-plate fractures (versus burst or retropulsed fractures)
  • Thoracolumbar location (T10-L2)
  • Segmental kyphosis less than 20 degrees
  • Cement volume greater than 5 ml during the procedure 5

Non-Pharmacological Management

• Individualized tailored exercise programs aimed at strengthening back muscles may help maintain bone density and reduce further fracture incidence 3
• Specific orthoses (braces) may help reduce kyphosis, improve mobility, and reduce pain, though evidence for specific types of braces is limited 2, 3
• Spinal stretching exercises and walking are recommended as part of long-term management 4
• For severe cases with significant deformity or neurological symptoms, surgical consultation should be considered 1

Special Considerations for Chronic Fractures

• Radiographic fracture assessment alone is not a reliable surrogate measure of symptomatic fracture; the presence of a fracture on imaging does not necessarily correlate with the source of back pain 2, 1
• For chronic wedge compression fractures with significant kyphosis (>20 degrees) or neurological symptoms, surgical approaches including spinal fusion may be necessary in select cases 6, 7
• The management of chronic vertebral fractures requires a combination of therapeutic interventions, physiotherapy, and patient education 3
• In cases of chronic fractures with severe and worsening pain despite conservative measures, a multidisciplinary approach including interventional radiology, surgery, and pain management is recommended 2

Treatment Algorithm

1. Begin with medical management: calcium/vitamin D supplementation, bisphosphonates, and calcitonin for pain control
2. Implement appropriate pain management with targeted analgesia
3. Start non-pharmacological approaches including specific exercise programs and appropriate bracing
4. If pain persists beyond 3 months despite conservative management, consider:
   • For patients without neurological symptoms: kyphoplasty may be considered
   • For patients with significant kyphosis or neurological symptoms: surgical consultation
5. Continue long-term osteoporosis management to prevent future fractures