What is the role of bracing in managing compression fractures?

Role of Bracing in Compression Fractures

The evidence does not support routine bracing for compression fractures—both braced and non-braced management produce equivalent outcomes in neurologically intact patients, making the decision to brace optional and at the treating physician's discretion.

Key Evidence-Based Recommendations

For Traumatic Burst Fractures (Neurologically Intact)

Bracing is optional, not mandatory. The Congress of Neurological Surgeons provides a Grade B recommendation that management with or without external bracing produces equivalent improvement in outcomes for neurologically intact patients with thoracic and lumbar burst fractures 1, 2.

• Level I randomized controlled trial evidence demonstrates no difference in pain, disability, or radiographic outcomes between braced versus non-braced patients at 6 months 1
• Both treatment approaches equally improve pain and disability scores over time 1
• Bracing is not associated with increased adverse events compared to no brace 1, 2

For Osteoporotic Compression Fractures

The evidence for bracing in osteoporotic compression fractures is inconclusive. The American Academy of Orthopaedic Surgeons states there is insufficient evidence to recommend for or against bracing 1.

• Only one Level II study examined bracing effects, which was downgraded to inconclusive because neither patient age nor fracture level was reported, and only a single brace type was studied 1
• The generalizability of bracing results to all brace types remains questionable 1

When Bracing May Provide Short-Term Benefit

Recent research suggests rigid bracing may reduce pain in the first 3-6 months after osteoporotic compression fractures, though this advantage disappears at longer follow-up 3.

• Moderate quality evidence shows rigid bracing decreases pain up to 6 months post-injury (SMD = -1.32,95% CI: -1.89 to -0.76) 3
• No difference exists in radiographic parameters, opioid use, function, or quality of life at any timepoint 3
• Soft bracing may be an adequate alternative to rigid bracing, as no difference was found between the two 3

Absolute Contraindications to Conservative Management (With or Without Brace)

Do not attempt conservative management in these scenarios:

• Any neurological deficit present 1, 2
• Significant vertebral collapse, angulation, or canal compromise 1, 2
• Fractures with TLICS score >4 suggesting instability 2
• Evidence of shear, rotation, or translational injury components 1, 2

Clinical Decision Algorithm

Step 1: Assess Neurological Status

• If neurological deficit present → Surgical evaluation required 1, 2
• If neurologically intact → Proceed to Step 2

Step 2: Evaluate Fracture Stability

• Assess for significant collapse, angulation, canal compromise, or TLICS >4 1, 2
• If unstable → Surgical intervention 1
• If stable → Proceed to Step 3

Step 3: Choose Conservative Management Approach

Either option is acceptable:

• Early mobilization without brace (supported by Level I evidence) 1
• Bracing with TLSO (if physician preference or patient comfort dictates) 1, 2

Step 4: Consider Short-Term Rigid Bracing for Pain Control

• For osteoporotic compression fractures with severe acute pain, rigid bracing may provide pain relief in the first 3-6 months 3
• This does not improve long-term outcomes but may enhance early comfort 3

Common Pitfalls to Avoid

Do not assume bracing is mandatory—high-quality evidence supports early mobilization without orthosis as equally effective 1, 2.

Do not order TLSO for patients with neurological deficits—these require surgical evaluation, not conservative management 2.

Do not expect bracing to prevent kyphotic progression—radiographic outcomes are equivalent between braced and non-braced patients in most studies 1, 3, though one recent trial showed vertebroplasty superior to bracing for maintaining sagittal balance 4.

Avoid prolonged immobilization—this can worsen bone loss and muscle weakness, particularly in osteoporotic patients 5.

Practical Considerations

For mild compression fractures (≤30% compression), early ambulation without external support is a validated approach, provided close clinical and radiographic follow-up is maintained 6.

The decision to use bracing should be based on physician judgment, patient comfort, and practical considerations rather than expectation of superior clinical outcomes 1, 2.