I had an interesting case that came into the door quite awhile back concerning a misdiagnosis of a thoracic compression fracture. I treat an older population in my rural area of work, so being aware of this condition is vital. I wrote a full blog article utilizing clinical decision guidelines from Henschke 2009 and Roman 2010 for Medbridge Education.
Click here to access the full article. Or, you can also access the entire Evidence-Based Examination of the Thoracic Spine Modules & Course Objectives to determine if this course if up your alley.
I will say that in addition to utilizing clinical decision making tools such as the ones provided by Henschke et al and Roman et al, I find that three other features aid in the hunch feeling of a vertebral compression fracture. Because as all clinicians know, clinical decision making tools aren’t rules but guidelines.
1. Examining posture, as low level evidence as it may be, can be a distinguishing factor. I wouldn’t use this in isolation but I have found that the most posterior vertebral segment (such as in a very kyphotic posture) is typically the level to fail.
2. Percussion Sign: Utilizing a closed-fist, firmly tap each spinal segment (usually in thoracic spine) cephalically to caudally and a positive sign would be reproduction of concordant symptoms. Typically it will correlation with #1 above.
3. Unable to lie down: The more I practice, the more I find how many people (especially men!) sleep in a recliner! Not sure if they are trying to get away from their wives or not 🙂 Reproduction of concordant symptoms while the patient tries to lie supine on your plinth can be a distinguishing factor too. I would do this last in the sequence of tests. Typically this will correlate with #1 and #2 above.
The latter two aren’t just my clinical thoughts, but have been studied as well. Langdon J et al in 2010 found the following values for the latter two tests (compared to MR scans):
Closed-fist percussion sign: 87.5% sensitivity and 90% specificity.
Supine Sign: 81.25% sensitivity and 93.33% specificity.
We can’t always be certain if someone has an underlying vertebral compression fracture or not, but utilizing the above information should be helpful in your differential diagnosis.
If you like this type of education and want to learn more, you can access a past blog article on the topic of manipulation, entitled “Busting the Myth that Manipulation is at End Range” written in November 2013 here. Also, sign up for future posts via e-mail, my twitter or facebook page located on your right.
Thanks for reading!