Vertebral Fractures in the Elderly: Radiologic Patterns and Red Flag Signs

BackgroundVertebral fractures are among the most common and clinically important outcomes of osteoporosis in older adults. They significantly contribute to pain, functional limitations, and a decline in quality of life. A significant proportion of these fractures remain clinically silent or present with vague symptoms, which often delays diagnosis. As a result, imaging plays a central role in detection. Distinguishing uncomplicated osteoporotic fractures from those caused by malignancy or infection is essential, as missed or delayed recognition may lead to inappropriate management and avoidable neurological complications.AimThis review aims to outline the typical radiological patterns of vertebral fractures in the elderly and to highlight key imaging “red flag” features that raise suspicion of secondary pathology or structural instability.MethodsA narrative review of the literature was conducted, drawing on published studies that address the epidemiology, imaging appearances, and management of vertebral fractures. The discussion focuses on the role of PET/CT, computed tomography, magnetic resonance imaging, nuclear medicine, and PET/CT, with particular attention to imaging features that help distinguish benign osteoporotic fractures from pathological fractures.ResultsPlain radiographs are useful for identifying vertebral deformity but have limited value in differentiating acute from chronic fractures. Computed tomography allows a more accurate assessment of cortical disruption, fracture morphology, and retropulsed fragments. Magnetic resonance imaging remains the reference standard for characterising vertebral fractures, as marrow signal changes, soft-tissue components, and posterior element involvement reliably separate benign from malignant causes. Nuclear medicine studies assist in assessing fracture chronicity, while PET/CT helps differentiate metastatic disease from benign lesions. Imaging features that should prompt concern include paraspinal soft-tissue masses, involvement of posterior elements, multiple contiguous vertebral lesions, and a convex posterior vertebral body margin.ConclusionCareful recognition of typical imaging patterns and associated red flag signs is fundamental in differentiating benign osteoporotic vertebral fractures from secondary causes. Accurate and timely diagnosis helps in appropriate management, minimises neurological complications, and ultimately improves outcomes in elderly patients.