how to differentiate between old fracture and new fracture in spine in mri
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vertebral compression fracture MRI
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MRI acute versus chronic vertebral compression fracture marrow edema T1 STIR radiology
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On spine MRI, the main discriminator is bone marrow edema.
| MRI feature | New / acute or subacute fracture | Old / chronic healed fracture |
|---|---|---|
| T1-weighted | Low signal in vertebral marrow, often band-like or diffuse | Normal fatty marrow returns, so relatively high T1 signal |
| T2 / STIR / fat-suppressed T2 | High signal marrow edema, often around the fracture line | No marrow edema. Vertebra may remain wedged or collapsed but is not STIR-bright |
| Fracture line | May show a visible low-signal line, cortical break, endplate disruption | Usually no active fracture line or surrounding reactive change |
| Paravertebral soft tissues | Edema or hematoma can be present after recent trauma | Usually absent |
| Follow-up | Edema and low T1 signal gradually decrease as it heals | Stable shape and fatty marrow appearance |
Practical rule:
A compressed vertebra that is bright on STIR/fat-sat T2 and dark on T1 is generally acute or subacute. A vertebra that remains compressed but has normal fatty marrow and no STIR edema is generally an old fracture.
A compressed vertebra that is bright on STIR/fat-sat T2 and dark on T1 is generally acute or subacute. A vertebra that remains compressed but has normal fatty marrow and no STIR edema is generally an old fracture.
Important qualifications:
- MRI estimates biologic activity, not an exact date. Edema can persist for weeks to months, especially with osteoporosis, ongoing mechanical stress, or delayed healing.
- An old compression deformity can sustain a new fracture on top of it. New focal STIR edema indicates the recent active component.
- If there is diffuse marrow replacement, a paraspinal/epidural mass, posterior wall convex bulge, or lesions elsewhere, consider a pathologic fracture from tumor or infection rather than a routine osteoporotic fracture.
- CT is better for defining the bony fracture morphology; MRI is better for age/activity, neural injury, ligament injury, hematoma, infection, and tumor assessment.
This aligns with Campbell's Operative Orthopaedics, which states that edema within a compressed vertebra supports an acute/subacute fracture, whereas chronic compression fractures typically regain normal marrow signal - Campbell's Operative Orthopaedics 15th Ed, pp. 1409-1414. The AJR overview of spinal marrow signal similarly describes acute edema as T1-low and T2/STIR-high.
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