crush fracture

Last reviewed 01/2018

These result from vertical compression and flexion, and may occur in the cervical, or thoraco-lumbar region. The majority are stable fractures. Sometimes they are pathological - associated with osteoporosis, trauma or spinal metastases.

• vertebral compression fractures usually occur when the front of the vertebral body collapses, and may be caused by trauma, cancer or osteoporosis
• osteoporotic vertebral compression fractures can cause the spine to curve and lose height, and can result in pain, difficulties in breathing, gastrointestinal problems, sleep disturbances and difficulties in performing activities of daily living
• high doses of analgesics used to treat such pain can have significant adverse effects
• symptoms and treatment of osteoporotic vertebral compression fractures can worsen quality of life and cause loss of self-esteem

prevalence of vertebral fractures increases with age and is more common in women (1)

• estimated that approximately 2.5 million people in England and Wales have osteoporosis
• prevalence of osteoporotic vertebral compression fractures is difficult to estimate because not all fractures come to the attention of clinicians and they are not always recognised on X-rays
• clinically evident osteoporotic vertebral compression fractures are associated with an increase in mortality.

If there is a degree of rotation associated with flexion one may also see 'lateral wedging' on the AP projection. This is often associated with compression of nerve roots and carries a poorer prognosis in terms of pain free recovery.

Radiographically; The lateral X-ray will show the anterior border of the vertebrae to be smaller than the posterior border. If the posterior border of the affected vertebrae is smaller in height than its neighbouring vertebrae there is the possibility that the injury is more violent than suspected and that there may be bony fragments encroaching on the spinal canal. The AP X-ray may show a lateral component to the wedging. If the anterior height of the affected vertebrae is greater than 50% of the posterior height, the fracture is likely to be stable. More marked wedging indicates damage to the posterior ligaments and instability, signs of which may include:

• avulsion fractures of the tip or the whole of the spinous process
• wide separation of the vertebral spines at the level of injury

Treatment

• treatment of unstable wedge fractures involves reduction - which may be open or closed and immobilisation - by plaster jacket or internal fixation. Stability is ultimately achieved by spontaneous anterior fusion or surgical fusion
• treating vertebral compression fractures aims to restore mobility, reduce pain and minimise the incidence of new fractures. Non-invasive treatment (such as pain medication, bed rest, and back braces) focuses on alleviating symptoms and supporting the spine
• NICE support the use of percutaneous vertebroplasty and percutaneous balloon kyphoplasty without stenting as options for treating vertebral fractures (1)
  • percutaneous vertebroplasty, and percutaneous balloon kyphoplasty without stenting, are recommended as options for treating osteoporotic vertebral compression fractures only in people:
    • who have severe ongoing pain after a recent, unhealed vertebral fracture despite optimal pain management and
    • in whom the pain has been confirmed to be at the level of the fracture by physical examination and imaging

Reference:

• NICE (April 2013). Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for treating osteoporotic vertebral compression fractures