Why most vertebral compression fractures are missed....
The other day I was chatting with a colleague about using a tuning fork to diagnose vertebral fractures. The theory is that the vibration of the tuning fork causes reverberation and therefore pain, at the fracture site. I’ve never found it to work!
I think that we see quite few spinal compression fractures in practice. They are easily missed. Up to 70% of them are undiagnosed (1). So I thought that I would run over the things that make me consider a vertebral compression fracture as a diagnostic possibility:
History:
History of trauma - typically a fall onto their bottom. Sometimes lifting a heavy suitcase. Falling off a horse.
Medication history: steroid use in particular, so patients with a history of inflammatory arthropathy, or inflammatory bowel disease. Long-term use of proton-pump inhibitors like Omeprazole or Lanzoprazole
Poor nutrition and lack of calcium absorption: alcoholics, lactose intolerance, smokers.
Examination
Pain is diffuse and they struggle to indicate where the pain is
Lack of palpatory tenderness, which is why they are told by other practitioners: ‘You haven’t broken anything’ (Note: the sacro-iliac is often a little tender after trauma, and it's easy to persuade ourselves that this is causing their pain. It isn’t).
Significant increase in pain when they get onto the treatment couch, turn over on it, and then when they get off it again.
Note the ‘mismatch’ between the above two points. This is often the real ‘clue’! Watch the 5min video below, so that you really 'get' this. It is the single biggest issue that has helped me to suspect compression fractures that have often been missed when the patient has consulted their GP:
What I do
I do not ‘adjust above and below’. It just aggravates things, in my experience.
Confirm, with a neurological examination, that there is no spinal cord compression.
Send for an X-Ray. I do this by writing to the GP and noting my findings and asking ‘is it worth considering an X-ray of the region’?
In the same letter, flag up the possibility of doing a bone density scan…..
I use sports tape to stabilise the area and localised paraspinal muscle dry needling, although the evidence base for doing this is poor.
I do not do physical treatments for at least two months.
Give fracture prevention advice: night light on the landing. Remove trip hazards in the home. Limit alcohol intake. Stop smoking. Strength and balancing rehabilitation. Remember that falls in the elderly (and therefore fractures) are often caused by multiple system failures. Clinicians need to consider themselves as geriatricians! Does the patient have an irregular pulse? How is their blood pressure? What is their eyesight and hearing like? Do they have any peripheral neuropathy? We have to remind ourselves to look at the patient as a whole!
Vertebral compression fractures are associated with increased mortality risk (2). We also need to remember that we are not just helping the patient to recover from the compression fracture that they have presented with, we should also do what we can to help them avoid future fractures (3) (4).
Homework:
Read the Clinical Guidance paper produced by the Royal Osteoporosis Society
References
