Sagittal computed tomography image of a patient with incapacitating mid-back pain 1 week after a motor vehicle accident.
Coronal computed tomography image of the patient.
A 49-year-old woman presents 1 week after sustaining a back injury in a motor vehicle accident. She was taken to the emergency department by ambulance following the injury, and radiographs taken at that time were reported as normal. She was discharged home but returned to the emergency department the next day for incapacitating mid-back pain. At that time, computed tomography scan of the chest showed a T7 compression fracture. Sagittal and coronal computed tomography images are taken. There are no retropulsed fragments or neurologic impingement. She denies any radicular symptoms, and bowel and bladder function are intact.
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The patient sustained a stable compression fracture at T7. Determination of fracture stability is made by assessing patient neurologic status, establishing whether the posterior ligament complex is intact, and verifying kyphosis <30 degrees and vertebral body height loss <50%. Injury to the posterior ligament complex should be suspected if the compression fracture occurs in nonosteoporotic bone and includes >50% vertebral height loss or >30 degrees of kyphosis.1
A brief period of bed rest, nonsteroidal anti-inflammatory drugs, pain medication, and muscle relaxants may be used for initial treatment of compression fracture. External support with bracing is generally used for patient comfort but may not be necessary in vertebral fractures with <10% vertebral height loss. Thoracolumbar sacral orthosis is the recommended brace for fractures at the level of T7. A thoracolumbar sacral orthosis provides support by keeping the spine in extension while resisting lateral and flexion bending. Early mobilization and extension exercises can be performed, as the rib cage provides intrinsic stability for fractures down to T10.1,2
For fractures at or above T5, cervical immobilization should occur because under-arm braces do not provide adequate support at these levels. A Philadelphia collar, Miami J collar, or sternal occipital mandibular immobilization brace is indicated for cervical fractures. Magnetic resonance imaging should be ordered for those with neurologic deficits, when the fracture is thought to be unstable, or if the acuity of the fracture is uncertain. Surgical correction of compression fracture may be indicated for unstable fractures or when neurologic deficits are present.2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).