Osteoporotic Compression Fractures¶

Definition¶

Osteoporotic compression fractures are the most common fragility fractures, occurring when weakened osteoporotic bone fails under normal physiological loading. They most commonly affect the thoracolumbar junction (T11–L2) and mid-thoracic spine (T7–T8). Many are asymptomatic and discovered incidentally.

Imaging Findings¶

Radiography¶

Anterior wedge deformity (most common pattern)
Biconcave deformity (fish vertebra)
Crush deformity (uniform height loss)
Genant grading: Grade 1 (20–25% height loss), Grade 2 (25–40%), Grade 3 (>40%)
Progressive thoracic kyphosis with multiple fractures

MRI¶

Acute — STIR hyperintensity (marrow edema), low T1 signal, band-like enhancement
Chronic — Normal fatty marrow signal (bright T1, low STIR), no enhancement
Kümmel disease — Intravertebral vacuum cleft (gas) or fluid cleft in a non-united fracture, indicating avascular necrosis

CT¶

Anterior cortical disruption without posterior wall involvement (distinguishes from burst fracture)
Normal interpedicular distance
Vacuum cleft in chronic non-union

Clinical Pearl

Multiple osteoporotic compression fractures create a progressive kyphotic cascade — each fracture increases the kyphosis, shifting the center of gravity forward, which increases loading on the anterior column and predisposes to additional fractures. This is the pathophysiology behind the progressive "dowager's hump" deformity.

Management¶

Conservative: analgesics, bracing, physical therapy, osteoporosis treatment (bisphosphonates, calcium, vitamin D)
Vertebral augmentation (vertebroplasty/kyphoplasty) for refractory pain after 4–6 weeks of conservative treatment
Always exclude malignancy — compression fracture may be the first sign of metastatic disease or myeloma

Key Points¶

Most common fragility fracture — thoracolumbar junction most affected
Genant classification grades severity by percentage of height loss
MRI STIR distinguishes acute (edema) from chronic (no edema) fractures
Always consider malignancy in the differential
Kümmel disease (vacuum cleft) indicates non-union with avascular necrosis

References¶

Genant HK, Wu CY, van Kuijk C, Nevitt MC. Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res. 1993;8(9):1137-1148. https://pubmed.ncbi.nlm.nih.gov/8237484/
Donnally CJ III, Margetis K, Varacallo MA. Vertebral Compression Fractures. In: StatPearls. Treasure Island (FL): StatPearls Publishing; updated 2025 May 4. https://www.ncbi.nlm.nih.gov/books/NBK448171/
Mauch JT, Carr CM, Cloft H, Diehn FE. Review of the Imaging Features of Benign Osteoporotic and Malignant Vertebral Compression Fractures. AJNR Am J Neuroradiol. 2018;39(9):1584-1592. https://pubmed.ncbi.nlm.nih.gov/29348133/
Chandra RV, Maingard J, Asadi H, et al. Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Fractures: What Are the Latest Data? AJNR Am J Neuroradiol. 2018;39(5):798-806. https://pubmed.ncbi.nlm.nih.gov/29170272/
Khan MA, Jennings JW, Baker JC, et al. ACR Appropriateness Criteria® Management of Vertebral Compression Fractures: 2022 Update. J Am Coll Radiol. 2023;20(5S):S102-S124. https://pubmed.ncbi.nlm.nih.gov/37236738/
Osteoporotic spinal compression fracture. Radiopaedia.org. https://radiopaedia.org/articles/osteoporotic-spinal-compression-fracture