What is the initial treatment for a mild compression fracture?

Initial Treatment for Mild Compression Fracture

For neurologically intact patients with a mild compression fracture, initiate conservative management with calcitonin 200 IU (nasal or suppository) for 4 weeks if presenting acutely (0-5 days from symptom onset), combined with analgesics, early mobilization, and bisphosphonate therapy to prevent additional fractures. 1, 2

Immediate Assessment Priorities

• Perform a complete neurological examination immediately to identify any deficits that would mandate urgent surgical intervention rather than conservative care—missing unstable fractures is a critical pitfall. 2, 3

• Obtain MRI without contrast to identify bone marrow edema indicating acute injury and to differentiate osteoporotic from pathologic fractures. 2, 3

• Assess for "red flags" including known malignancy, neurological symptoms, or signs of spinal instability that would require immediate surgical referral. 3

Acute Phase Management (0-5 Days)

• Administer calcitonin 200 IU (nasal or suppository) for 4 weeks if the patient presents acutely, as this provides clinically important pain reduction at 1,2,3, and 4 weeks. 1, 2

• Use NSAIDs as first-line analgesics for pain control. 2, 3

• Limit narcotic use to avoid complications of sedation, falls, and decreased physical conditioning—overuse of narcotics is a common pitfall. 2, 3

• Avoid prolonged bed rest, which leads to deconditioning, bone loss, thromboembolism, and increased mortality risk. 2, 3

Early Mobilization Strategy

• Permit slow, regular walking starting with 10-minute periods, gradually increasing duration. 2

• Allow range-of-motion exercises and light calisthenics that generate 40-70% of maximum oxygen consumption. 2

• Activities should remain moderate intensity to prevent fracture progression while allowing initial healing. 2

Fracture Prevention Therapy

• Initiate ibandronate or strontium ranelate to prevent additional symptomatic fractures in patients presenting with an osteoporotic compression fracture. 1, 2

• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D supplementation (800 IU/day). 2

• Avoid high pulse dosages of vitamin D which increase fall risk. 2

Bracing Considerations

• Bracing is optional for neurologically intact patients with compression fractures, as both braced and non-braced approaches show equivalent improvement in pain and disability outcomes. 4

• The evidence for bracing is inconclusive due to limited studies that did not report patient age or fracture level, and only evaluated a single brace type. 1

When to Consider Vertebral Augmentation

• Reserve vertebral augmentation (kyphoplasty or vertebroplasty) for patients with persistent severe pain after 3 weeks to 3 months of conservative management. 2, 3

• Consider vertebral augmentation if spinal deformity or pulmonary dysfunction develops. 2, 3

• Vertebral augmentation provides immediate and substantial improvement in pain and mobility when conservative management fails, as approximately 1 in 5 patients develop chronic back pain despite conservative treatment. 3

Critical Pitfalls to Avoid

• Do not prolong bed rest beyond what is absolutely necessary, as this dramatically increases risk of deconditioning, bone loss, thromboembolism, and mortality. 2, 3

• Do not overuse narcotics, which cause sedation, increase fall risk, and worsen physical conditioning. 2, 3

• Do not miss unstable fractures by performing inadequate neurological examination—complete assessment is essential. 2, 3

• Do not delay surgical referral if any neurological deficits, frank spinal instability, or spinal cord compression are present—these require immediate surgical consultation with corticosteroid therapy initiated immediately. 2, 3