How should a 13-year-old boy with a mild L2 vertebral compression fracture from a fall be managed non‑operatively?

Management of Mild L2 Vertebral Compression Fracture in a 13-Year-Old

For this 13-year-old boy with a mild L2 compression fracture from a fall, conservative management with pain control and early mobilization is the appropriate treatment—bracing is optional and provides no proven benefit over mobilization alone. 1, 2

Initial Assessment

Perform a thorough neurological examination immediately to document any deficits, as any neurological involvement fundamentally changes management toward surgical consultation. 2 In this neurologically intact patient, conservative management is appropriate.

Obtain CT imaging if not already done to fully characterize the fracture pattern, assess for canal compromise, vertebral collapse, and kyphotic deformity. 2 The x-ray showing "mild" compression suggests this is likely an AO Type A fracture without significant instability.

Conservative Management Protocol

Pain control with analgesics and early mobilization as tolerated is the primary treatment. 2 High-quality Level I randomized controlled trial evidence demonstrates that bracing provides no advantage over early mobilization without orthosis—both produce equivalent outcomes in pain, disability, and radiographic parameters at 6 months. 1

If a TLSO brace is used (at physician discretion), limit duration to maximum 8 weeks to avoid trunk muscle atrophy. 2 The American Association of Neurological Surgeons provides a Grade B recommendation that management with or without external bracing produces equivalent outcomes—the decision is entirely at the treating physician's discretion. 1, 2

Pain Management Specifics

• Use NSAIDs as first-line agents 3
• Reserve narcotics for severe pain, using with caution given sedation, nausea, and fall risks 3
• Most patients experience spontaneous resolution of pain within 6-8 weeks even without medication 3

Activity Modification

Early mobilization is superior to prolonged bed rest. 1 Encourage gradual return to activities as pain permits, avoiding high-impact activities and heavy lifting during the healing phase.

Follow-Up and Monitoring

Repeat imaging is necessary to monitor for:

• Progressive vertebral collapse 2
• Increasing kyphotic deformity 2
• Delayed instability 2

Schedule follow-up imaging at 4-6 weeks and again at 3 months to ensure appropriate healing without progression.

Red Flags Requiring Immediate Surgical Consultation

Do not continue conservative management if any of the following develop:

• Any new neurological deficit 2
• Significant vertebral collapse, angulation, or canal compromise 1, 2
• Progressive kyphotic deformity on follow-up imaging 2
• Evidence of shear, rotation, or translational injury components 1

Common Pitfalls to Avoid

Do not assume bracing is mandatory—high-quality evidence supports early mobilization without orthosis as equally effective, and bracing may actually delay return to normal function. 1

Do not order prolonged bed rest—this increases complications and delays recovery without improving outcomes. 3

Do not miss concomitant injuries—consider spinous process fractures at the level just above the compression fracture (occurs in 3.5% of cases). 4

Expected Outcomes

Most patients with mild compression fractures treated conservatively have complete resolution of symptoms. 3 However, approximately 40% may have some persistent pain at 1 year, and one in five may develop chronic back pain despite conservative treatment. 2 This underscores the importance of close follow-up and consideration of alternative diagnoses if pain persists beyond expected timeframes.