Does an older adult with a new atraumatic compression fracture and likely underlying osteoporosis require immediate transfer for orthopedic evaluation or is outpatient follow-up sufficient?

Management of New Atraumatic Compression Fractures

Outpatient follow-up is sufficient for most older adults with new atraumatic compression fractures; immediate orthopedic transfer is not routinely required unless there are specific high-risk features such as neurologic deficits, progressive deformity, or inability to manage pain. 1, 2

Immediate Evaluation and Disposition

Most atraumatic vertebral compression fractures in older adults can be managed conservatively without urgent orthopedic consultation 2. The key decision point is identifying features that require immediate specialist evaluation versus those that can be managed with outpatient follow-up.

Indications for Immediate Transfer/Consultation

Transfer for urgent orthopedic or spine surgery evaluation is indicated only when:

• Neurologic deficits are present (progressive myelopathy, cauda equina syndrome) 2
• Progressive deformity despite conservative management 2
• Intractable pain unresponsive to conventional pain management 2
• Inability to mobilize or return to baseline function with standard care 2

Appropriate for Outpatient Management

The vast majority of osteoporotic compression fractures follow a benign and self-limited course with gradually resolving pain and can be managed with outpatient follow-up 2. These patients should receive:

• Pain medication and activity modification as initial treatment 2
• Outpatient orthopedic or spine referral within 1-2 weeks for persistent symptoms 1
• Bracing occasionally if indicated for pain control 2

Critical Metabolic Bone Disease Evaluation

The most important intervention is systematic evaluation and treatment of underlying osteoporosis, which is frequently neglected. 1

Imminent Fracture Risk

• Fracture risk is highest in the immediate 1-2 years following a vertebral compression fracture, described as "imminent fracture risk" 1
• Vertebral fractures increase the risk of subsequent vertebral fractures 5-fold and other fractures 2-3 fold 3
• Each patient aged 50 years and over with a recent fracture should be evaluated systematically for the risk of subsequent fractures 1

Required Outpatient Workup

The following evaluations should be initiated or arranged before discharge:

• DEXA scan (if not recently performed) to assess bone mineral density 1, 3
• Vertebral imaging to identify additional subclinical vertebral fractures 1
• Laboratory evaluation: calcium, vitamin D, parathyroid hormone, basic metabolic panel, thyroid function 1
• Assessment for secondary causes of osteoporosis 1

Fracture Liaison Service Referral

The most effective organizational structure for preventing subsequent fractures is referral to a Fracture Liaison Service (FLS) with a dedicated coordinator 1. This approach:

• Increases medication initiation and adherence by 38% compared to 17% without FLS (risk difference 20%, 95% CI 16-25%) 4
• Significantly improves implementation of osteoporosis treatment (45% vs 26% in control groups) 1
• Provides systematic identification, investigation, and intervention 1

If an FLS is not available, ensure direct referral to endocrinology, rheumatology, or an orthopedic bone health clinic for osteoporosis management 1

Pharmacologic Intervention

Most fragility fractures occur in individuals with BMD T-scores higher than -2.5, confirming skeletal fragility even with preserved bone density 1. Therefore, a new atraumatic compression fracture itself is an indication for pharmacologic treatment regardless of BMD 1.

Treatment Recommendations

• Antiresorptive agents (bisphosphonates or denosumab) are first-line for high-risk patients, reducing vertebral fractures by 52 per 1000 person-years 4
• Anabolic agents (teriparatide, abaloparatide, romosozumab) should be considered for very high-risk individuals with recent vertebral fractures, followed by antiresorptive therapy 4
• Calcium (1000-1200 mg) and vitamin D (600-800 IU) supplementation 4

Common Pitfalls to Avoid

The Osteoporosis Care Gap

Approximately 70% of patients who could benefit from osteoporosis treatment do not receive it 1. This represents a patient care crisis, as:

• Two-thirds of vertebral compression fractures are not accurately diagnosed and therefore not treated 5
• Most patients with fragility fractures are not identified as having underlying metabolic bone disease 1
• Even when diagnosed, evaluation and pharmacological intervention is only offered to a small percentage 1

Differential Diagnosis Considerations

While osteoporosis is the most common cause, the differential diagnosis must include 2, 6:

• Malignancy (metastases, multiple myeloma)
• Infection (osteomyelitis)
• Other metabolic bone diseases (osteomalacia, hyperparathyroidism, Paget's disease)

MRI is the most helpful radiological investigation to distinguish between metastatic and osteoporotic compression fractures when the diagnosis is uncertain 6

Documentation and Communication

Ensure the discharge summary explicitly documents:

• The presence of a fragility fracture indicating skeletal fragility 1
• Need for osteoporosis evaluation and treatment 1
• Specific outpatient referrals arranged 1
• Patient education provided about fracture risk 1