Compression Fracture on X-ray: Imaging Findings

Acute and subacute compression fractures show marrow edema on MRI — low signal on T1 and high signal on STIR (short tau inversion recovery) sequences — reflecting the bone marrow edema phase that persists for weeks to months. Chronic fractures have normalized marrow signal isointense to adjacent vertebrae on both sequences. The distinction is clinically critical because acute fractures may respond to percutaneous vertebroplasty or kyphoplasty within 6–8 weeks of onset, while chronic fractures do not benefit. Gadolinium enhancement patterns also differ: benign fractures show diffuse or bandlike enhancement, whereas pathological fractures from metastatic disease or myeloma show heterogeneous nodular enhancement and often convex posterior cortex bulging.

Treatment decisions consider fracture morphology, posterior ligament integrity, and neurological status. A two-column rule alone does not determine whether surgery is needed.

Fragility fractures occurring with minimal or no trauma in patients over 50 should trigger dual-energy X-ray absorptiometry (DXA) to assess bone mineral density and guide osteoporosis treatment. Red flags suggesting pathological fracture from malignancy include fracture above T4, multiple non-contiguous fractures, abnormal soft-tissue mass, convex posterior cortex, pedicle destruction visible on CT, age under 55 without osteoporosis, or a history of primary malignancy. MRI with gadolinium or CT-guided biopsy is required when malignancy is suspected. Myeloma should be excluded with serum and urine protein electrophoresis, immunofixation, and free light chain assay in any patient over 50 with vertebral collapse and an elevated erythrocyte sedimentation rate.