A JBJS review sets out what is known about vertebral compression fractures and pelvic insufficiency fractures. Both are common, both raise mortality and morbidity, and both are routinely missed — many patients are asymptomatic, others have their symptoms attributed to degenerative disease or to the fall itself, and pelvic and sacral fractures are genuinely difficult to see on plain radiographs.
Most do not need an operation. Non-operative treatment centres on pain control, restoring mobility and activities of daily living, and nutritional support. The surgical indications are narrow and specific: intractable pain, poor functional ability, radiographic evidence of deterioration, and neurological deficit. Secondary fracture prevention is described as critical, and may itself speed recovery.
The practical consequence is about imaging thresholds. An older patient with new back pain after a minor fall, or unexplained inability to weight-bear with a normal pelvic radiograph, is the case that gets sent home. Cross-sectional imaging in that setting is not over-investigation, and the diagnosis matters not because it changes the operation but because it triggers the bone protection that prevents the next fracture.
- In an older patient who cannot weight-bear with a normal pelvic radiograph, go to CT or MRI
- Treat new back pain after a low-energy fall as a fracture until imaged, not as degenerative pain
- Start secondary prevention at the index fracture, not at the fracture clinic follow-up
- Address nutrition and mobility explicitly in the non-operative plan
- Reserve surgery for intractable pain, functional failure, radiographic deterioration or neurological deficit
Why it matters
These fractures are missed not because they are rare but because the first-line imaging does not show them.
Don't overread it
This is an instructional review summarising current practice, not new comparative evidence.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for orthopaedics, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free