An elderly patient with a history of COPD presents with back pain radiating to the chest. After an extensive workup, a CT scan shows a vertebral compression fracture. You percuss the area and find that this reproduces the pain. Is this the cause of her pain?
Sometimes in emergency medicine we face the dilemma of a new vertebral compression fracture. Is it new or old? MRI can help, but is hard to obtain still. Until recently there was not much literature on this. Closed fist percussion has always been used, and a recent article supports it.(Langdon Ann R Coll Surg Engl 2010) The author also introduces the supine sign, that many of these patients have substantial worsening of their pain when lying supine. In fact this sign was 81% sensitive and 93% specific. Although those statistics may turn out to be less helpful when applied to a broader population, this is an interesting addition to our diagnostic approach at the bedside.
Take home points:
Use closed fist percussion to determine with a compression fracture is acute
Consider pain with supine posture as a sign supporting an acute fracture