Incidental Vertebral Fractures Discovered With Chest Radiography in the Emergency Department

BACKGROUND: Vertebral fractures are common and usually an indication for osteoporosis treatment. However, screening is not recommended, and many fractures go undetected. Our objectives were to determine the utility of chest radiographs for detecting previously unrecognized vertebral fractures; document rates of recognition; and evaluate osteoporosis treatments. METHODS: In 2001, we conducted a cohort study in a random sample of 500 patients older than 60 years who presented to our emergency department and underwent chest radiography for any indication. The primary outcome was prevalence of moderate-to-severe vertebral fractures determined by independent radiograph review using validated semiquantitative techniques. Secondary outcomes were rates of fracture recognition according to official radiologists' reports and rates of osteoporosis diagnosis and treatment. We conducted multivariable regression analyses to determine correlates of study-defined and officially reported fractures. RESULTS: We excluded 36 patients with inadequate radiographs and 5 for other reasons. Mean age was 75.2 years; 47% were women; and 80% were white. The prevalence of moderate-to-severe vertebral fractures according to independent review was 72 (16%) of 459; 29 (40%) of these fractures were not recorded in the official radiologists' report (kappa = 0.64; 95% confidence interval CI, 0.53-0.75). A history of osteoporosis was the only independent correlate of having a vertebral fracture identified by independent review (adjusted odds ratio OR, 2.18; 95% CI, 1.14-4.17) or by official report (adjusted OR, 4.97; 95% CI, 0.95-25.86). Of the 72 patients with fractures, only 18 (25%) had histories of osteoporosis or received osteoporosis medications. CONCLUSIONS: One in 6 elderly patients who underwent chest radiography in our emergency department had clinically important vertebral fractures. Nevertheless, only 43 (60%) of these fractures were reported, and only 25% of patients with fractures received a diagnosis of or treatment for osteoporosis.