Delayed Diagnosis of Compression Fracture Causes Permanent Disability

The patient reported tenderness in her lower ribs and lumbar spine. Examination of the rib cage revealed tenderness in the lower thoracic cavity with tenderness present throughout the length of the lumbar spine upon palpation. The physician ordered X-rays of the ribs, chest, and spine to rule out bony pathology. The imaging studies were negative for any acute osseous findings and there was no evidence of any acute intra-thoracic processes. There were some signs of progressive degenerative changes and rotatory scoliosis. The working diagnosis was contusion and strain of the thoracolumbar spine and lower rib cage. The patient was advised to ice the area for twenty-four to forty-eight hours and then heat to the affected areas, as well. She was also prescribed non-steroid anti-inflammatory agents (NSAIDs).

After several months of no relief, the patient underwent additional imaging studies that confirmed a compression fracture of the T10 vertebra. The T10 compression fracture that was visible on the plain films taken when the patient first presented to her physician were discovered. The delay in treatment led to further compression of T10 which eventually led to an 80% wedge deformity with an 75% loss of height anteriorly. This resulted in the patient becoming permanently disabled and unable to work.

Question(s) For Expert Witness

Should the compression fracture have been identified on the initial imaging studies, and, given the time frame, could there have been additional efforts made to alter this patient's outcome?

Expert Witness Response E-006271

It is possible that a more timely diagnosis could have altered this patient's outcome. Initial imaging studies, usually involving a plain X-ray of the dorsolumbar spine, should confirm the diagnosis evidenced by anterior wedging of one or more vertebrae with vertebral collapse, vertebral end-plate irregularity, and general bone demineralization. If the X-ray was inconclusive to the physician, he or she could schedule the patient for an MRI or CT scan. Additional efforts could have been aimed at properly managing this patient, which includes calcitonin, bisphosphonates, parathyroid hormone, muscle relaxants, and bracing. The physician could have also recommend lifestyle modifications that reduce the risk of future compression fractures including exercise, smoking cessation, and reduced alcohol consumption. Most importantly, proper follow-up should have been performed with this patient to ensure proper diagnosis and treatment of the ensuing condition.