What is the recommended initial management for multiple thoracic compression fractures in an older adult with osteoporosis following low‑energy trauma?

Treatment for Multiple Thoracic Compression Fractures

For an older adult with multiple thoracic compression fractures from osteoporosis, begin immediately with multimodal analgesia (scheduled acetaminophen every 6 hours plus short-term opioids for breakthrough pain), activity modification with bracing, and initiate bisphosphonate therapy within 6 months—approximately 90% of these fractures are managed conservatively without surgery. 1, 2

Immediate Pain Management (First 24-48 Hours)

• Administer intravenous acetaminophen 1000 mg every 6 hours as first-line analgesia, which is both effective and safe in elderly trauma patients 3
• Add short-acting opioids only for breakthrough pain at the lowest effective dose for the shortest duration, recognizing the high risk of morphine accumulation, over-sedation, respiratory depression, and delirium in older adults 3
• Consider calcitonin 200 IU intranasal daily for 4 weeks following fracture onset to provide additional pain relief during the acute phase 3
• Avoid NSAIDs as routine therapy given the high risk of adverse events (gastrointestinal bleeding, renal impairment, cardiovascular events) and drug interactions in elderly patients, though they may be added cautiously in selected cases with severe pain 3
• Apply non-pharmacological measures including immobilization with a thoracolumbar orthosis (brace) and ice packs as adjuncts to medication 3

Conservative Management (Weeks 1-12)

• Prescribe a thoracolumbar orthosis (TLSO brace) for activity modification and pain control, though recognize that bracing alone does not improve outcomes compared to early mobilization with analgesia and physiotherapy 4, 5
• Begin early mobilization and physical therapy within days of fracture, avoiding prolonged bed rest which leads to further bone loss, deconditioning, and complications 1, 2
• Ensure adequate fluid management and correct any electrolyte disturbances, particularly in hospitalized patients 3, 1
• Monitor for complications including progressive kyphosis, neurologic deficits (rare but possible with multiple fractures), and development of chronic pain beyond 2 months 3, 4

Comprehensive Osteoporosis Evaluation (Within First Week)

Every patient aged 50+ with compression fractures requires systematic fracture-risk assessment even without awaiting "perfect consolidation"—the fracture itself is diagnostic for osteoporosis. 1, 2

• Order DXA scanning of lumbar spine and hip to quantify bone mineral density 1, 2
• Obtain lateral thoracic and lumbar spine radiographs (T4-L4) to detect additional subclinical vertebral fractures, which are present in up to two-thirds of cases and only one-third are symptomatic 3, 1, 2
• Measure serum calcium, 25-hydroxy-vitamin D, parathyroid hormone, albumin, creatinine, and TSH to identify secondary causes of osteoporosis 2
• Assess falls risk through detailed history, balance testing, vision evaluation, home environment review, and medication reconciliation 1, 2
• Review clinical risk factors including age, prior fracture history, family history, smoking, alcohol use, glucocorticoid therapy, and anticonvulsant use 1, 2

Pharmacological Osteoporosis Treatment (Initiate Within 6 Months)

Start oral bisphosphonates within 6 months post-fracture to maximize benefit during the 24-month period of highest subsequent fracture risk—do not delay awaiting radiographic healing. 1, 2

• Prescribe alendronate 70 mg weekly OR risedronate 35 mg weekly as first-line therapy, which reduces vertebral fractures by 68%, hip fractures by 40%, and non-vertebral fractures by 20% 1, 2
• Always combine bisphosphonates with calcium 1000-1200 mg daily and vitamin D 800 IU daily, as this combination reduces non-vertebral fractures by 15-20% and falls by 20% 1, 2
• Avoid high-pulse (large single) doses of vitamin D, which paradoxically increase fall risk 1, 2
• Plan for 3-5 years of initial bisphosphonate therapy, with extension considered for patients who remain at high risk after reassessment 1
• Consider alternative agents (denosumab, teriparatide, romosozumab) for patients intolerant to bisphosphonates or with contraindications, though bisphosphonates remain first-line 1, 2

Rehabilitation Protocol (Ongoing)

• Begin early post-fracture physical training and muscle-strengthening exercises within days of injury, focusing on range of motion while avoiding above-chest-level activities until healing is evident 1, 2
• Continue long-term balance training and multidimensional fall-prevention programs indefinitely, as fracture risk remains markedly elevated for 24 months before gradually declining 1, 2
• Counsel patients on smoking cessation and alcohol limitation (no more than 2 drinks daily) as part of comprehensive fracture prevention 1, 2

Surgical Intervention (Reserved for Specific Indications)

Surgery is indicated only in approximately 10% of cases—specifically for patients with neurologic deficits, progressive deformity with cord compression, or intractable pain unresponsive to 2-3 months of conservative management. 3, 1, 4

• Consider vertebroplasty or kyphoplasty for patients with persistent severe pain beyond 2-3 months of conservative therapy, though the 2011 AAOS guideline issued a strong recommendation against vertebroplasty based on sham-controlled trials 3, 4
• Reserve posterior decompression and instrumented fusion for patients with neurologic deficits or progressive kyphotic deformity causing spinal cord compression, recognizing the high technical demands and complication risks in osteoporotic bone 4, 6
• In patients with severe thoracic kyphosis (>70-80 degrees) from multilevel fractures causing sagittal imbalance, staged vertebral augmentation with osteotomies may be considered, though this remains complex with significant risks 6

Multidisciplinary Coordination

• Establish orthogeriatric co-management immediately for hospitalized patients, which reduces 1-year mortality, shortens hospital stay, and improves functional outcomes 3, 1, 7
• Designate a local coordinator (Fracture Liaison Service) to ensure DXA scanning, vertebral imaging, osteoporosis treatment initiation, and patient education, as this raises long-term medication adherence from 1-65% in usual care to up to 90% 1, 7
• Coordinate care among orthopedic surgeons, rheumatologists/endocrinologists, geriatricians, and primary care physicians to ensure no patient is discharged without osteoporosis treatment 1, 7

Critical Pitfalls to Avoid

• Do not postpone osteoporosis treatment awaiting "complete fracture healing"—the fracture itself is diagnostic and the highest risk period for subsequent fractures is the first 6-24 months 1, 2
• Do not discharge patients after acute fracture care without initiating or arranging osteoporosis therapy—diagnosis rates are only 1-45% and treatment rates only 1-65% in routine practice 1
• Do not assume pain management alone is sufficient—underlying osteoporosis must be addressed to prevent the next fracture 1, 2
• Do not overlook assessment for additional vertebral fractures—two-thirds of vertebral fractures are asymptomatic and only detected on imaging 3, 1, 2
• Do not prescribe prolonged bed rest—early mobilization prevents deconditioning and further bone loss 1, 2