Vertebral End Plate Fracture

Normal Anatomy

• End Plate– Thin layer of hyaline

cartilage between bone and intervertebral disc

– Prevents highly hydrated nucleus from bulging into adjacent vertebral bone

– Absorbs hydrostatic pressure from mechanical loading of the spine

– Allows diffusion of nutrients between bone and disc

Pathophysiology• With age end plate cartilage

thins and calcifies– Affects distribution of IVD

pressure to vertebral– Affects diffusion of nutrients

• Communication develops between nucleus and highly innervated vertebral marrow

• Schmorls Nodes– Protrusion of nucleus into

vertebral body– Pathological when associated

with fibrovascular bone marrow changes and bone marrow lesion

Pathophysiology

• 3 types described– Avulsion

• Bending motion that causes traction of interface between annulus and end plate

• More common vertebral rim in lower lumbar spine• Greater ROM available so more traction

– Traumatic node• End plate fragment from excessive compression with healthy nucleus

pulposus• More common central end plates upper lumbar and thoracolumbar spine• Trabecular bone density is lower, end plates weaker, subcondral softening is

more severe

– Central End Plate Fracture with Exposed Trabecular• Excessive compression with degenerative pulposus

Pathophysiology

Mechanism Of Injury

• Traumatic– Heavy axial compression– Falling into standing or

seated position– Heavy lifting

• Insidious– Repeated axial

compression– Repetitive

flexion/Extension

Associated Pathologies

• Degenerative Disc Disease

• Disc Herniation• Osteoporosis• Vertebral Fractures

Subjective

• Central Low back Pain• Sudden or insidious • History of axial compression or repetitive

traction (flexion/extension)• Aggravated by standing or walking• Pain with jumping, running, landing• Eases lying down

Objective

• Reduced flexion/extension

• Tenderness palpation soft tissue

• Tenderness and stiffness joint PA’s

Special Tests

• Heel drop from standing– In standing, go onto tip

toes– Drop onto heels– Axial compression

causes pain

Further Investigation

• Discography• MRI• X-ray• Often missed on

imaging

General Management

• Management of symptoms and pain relief• Activity modification• Relative Rest• Nearly always conservative

Conservative - Management

• Pain Relief– NSAID’s, Ice, Massage

• Restore Normal Range of Movement– Hips, Thoracic and Lumbar Spine– Soft tissue techniques, mobilisations

• Restore Normal Muscle Activation– Multifidus, erector spinae, glutes, obliques, trans abs

• Restore Dynamic Stability– Gradually re-expose to axial compression to develop

adequate neuromuscular control to reduce force through vertebrae

Plan B - Management

• Vertebroplasty– Only in very severe cases and in combination with

a fracture of the vertebrae