The Domino Effect: When Vertebral Fractures Lead to Sternal Pain 

The Domino Effect: When Vertebral Fractures Lead to Sternal Pain | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report The Domino Effect: When Vertebral Fractures Lead to Sternal Pain Mayalen Uthurriague, Maëva Masson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6605151/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Sternal insufficiency fractures remain an uncommon but increasingly recognized condition in elderly patients with advanced osteoporosis. They typically manifest as acute anterior chest pain, which can closely mimic cardiac pathology, leading to potential delays in diagnosis if not investigated with appropriate imaging. Case Presentation: We describe the case of an 81-year-old woman with a history of severe osteoporosis who was admitted for management of a painful osteoporotic compression fracture at the fifth thoracic vertebra (T5). Her osteoporosis had previously been managed with oral bisphosphonates, followed by three years of denosumab therapy. However, no antiresorptive consolidation therapy was administered after her last denosumab injection, given nine months prior, due to recent dental issues. Within 24 hours of admission, the patient developed sudden-onset anterior chest pain while moving from a seated position. The pain was reproducible on palpation over the sternum. A chest CT scan revealed a spontaneous, non-displaced transverse sternal fracture. The recent vertebral collapse had further accentuated her thoracic kyphosis, likely increasing mechanical stress on the sternum and contributing to the fracture. Management included local application of lidocaine patches, which provided effective pain relief, along with a single intravenous dose of zoledronic acid for osteoporosis consolidation. Conclusion: This case underscores the importance of considering sternal insufficiency fractures in elderly patients with osteoporosis who present with chest pain, especially in the context of recent vertebral fractures or postural deformities. It also highlights the potential complications associated with denosumab discontinuation when not followed by appropriate consolidation therapy. Finally, it draws attention to the utility of topical lidocaine as a simple, well-tolerated option for localized bone pain in frail, elderly patients. Introduction Sternal fractures are typically the result of direct trauma, most commonly occurring in motor vehicle accidents or high-energy falls. However, spontaneous or insufficiency sternal fractures are an increasingly recognized clinical entity in elderly patients with advanced osteoporosis. These fractures can present with acute chest pain that mimics cardiac conditions, posing diagnostic challenges ( 1 ). The exact incidence of insufficiency sternal fractures remains poorly documented, as they are often unrecognized or confused with other pathologies. We present here a rare case of spontaneous sternal fracture in an elderly woman with severe osteoporosis, that occurred shortly after a thoracic vertebral fracture, illustrating the cascade of complications that can arise from uncontrolled osteoporosis and denosumab discontinuation without appropriate consolidation therapy. Case Presentation Medical History An 81-year-old woman was admitted for the management of a highly painful osteoporotic compression fracture of the fifth thoracic vertebra (T5). Her medical history included hypertension, long-standing asthma, degenerative thoracolumbar scoliosis, an unclassified inflammatory arthritis diagnosed in 2014 (currently in remission), and osteoporosis. The diagnosis of osteoporosis was made in 2015 following a low-energy distal radius fracture. Contributing factors included systemic corticosteroid use in 2014 (4-month tapered course), and ongoing treatment with inhaled corticosteroids for asthma. In contrast, she had no history of early menopause, low body mass index, tobacco use, or excessive alcohol intake. She had undergone hormone replacement therapy for 10 years after menopause. She had regular monthly vitamin D supplementation and a calcium-rich diet (2–3 dairy products per day) She was initially treated with oral bisphosphonates (risedronate 35 mg once weekly) for four years, but this was discontinued in 2019 due to poor gastrointestinal tolerance (persistent nausea). She was then switched to denosumab (60 mg subcutaneously every six months) for three years. The last injection was given in January 2022. Post-denosumab consolidation therapy with intravenous zoledronic acid was not administered due to recent dental issues. Bone mineral density (BMD) assessment in May 2022 showed improvement, with a T-score of -2.1 at the lumbar spine and − 2.5 at the femoral neck. BMD had steadily improved over time: T-score at the spine had increased from − 3.1 in 2016 to -2.7 in 2018 and then to -2.1 in 2022. The femoral neck T-score remained stable at -2.5. Current Clinical Presentation In October 2022, nine months after her last denosumab injection, the patient developed acute mid-thoracic pain during minimal exertion (bending to pick up an object). Spine radiography revealed an osteoporotic compression fracture of the fifth thoracic vertebra (T5). The intensity of the pain and resulting functional impairment made it impossible for the patient to remain at home, leading to hospital admission for pain management. On admission, laboratory workup showed a hemoglobin level of 12.5 g/dL with normocytic indices, leukocytes at 7.4 G/L, and platelet count at 305 G/L. Renal function was preserved (CKD-EPI eGFR 85 mL/min/1.73m²), with no abnormalities in the electrolyte panel or calcium-phosphate balance (calcium 2.34 mmol/L, phosphate 1.1 mmol/L). Liver enzymes were within reference range. Thyroid-stimulating hormone (TSH) was 0.72 µU/mL, parathyroid hormone (PTH) was 10 pg/mL, and 25-hydroxy-vitamin D was measured at 35 ng/mL. Serum protein electrophoresis was unremarkable. C-terminal telopeptides of type I collagen (CTX) were not measured. Hospital Course Less than 24 hours after admission for the vertebral fracture, the patient experienced sudden-onset anterior chest pain while moving from a seated position, rated 8/10 on the numerical scale. The pain was aggravated by respiratory movements and sternal palpation. It was accompanied by tachycardia (102 beats/minute), hypertension (204/96 mmHg), and diaphoresis. Physical examination revealed focal tenderness over the sternum, without crepitus or visible deformity. Cardiac and pulmonary auscultation were unremarkable, and the ECG showed sinus rhythm with no signs of ischemia, ruling out acute coronary syndrome. A chest computed tomography (CT) scan was performed. Sagittal reconstructions revealed a spontaneous transverse sternal fracture without significant displacement ( Figure A ,), as well as the previously identified T5 vertebral compression fracture ( Figure B ). The vertebral collapse had further worsened her pre-existing thoracic kyphosis. This postural imbalance, combined with her advanced age and severe osteoporosis, was identified as the likely combination of contributing factors for the sternal insufficiency fracture. Management She was treated symptomatically with 5% lidocaine patches applied locally to the painful sternal area (one patch every 12 hours), which resulted in rapid and substantial pain relief. Zoledronic acid was administered intravenously (5 mg single infusion) the day following the discovery of the sternal fracture, without complications. Vitamin D supplementation was continued. Discussion This case illustrates a spontaneous sternal insufficiency fracture in an elderly woman with severe osteoporosis, occurring within 24 hours of hospitalization for an osteoporotic vertebral compression fracture. The close temporal association strongly suggests a biomechanical relationship between the two events. Vertebral collapse with resulting postural changes—particularly increased thoracic kyphosis—can shift mechanical loads to the anterior thoracic structures, increasing the risk of non-traumatic sternal fractures. In the aging population, progressive ossification of costal cartilages reduces thoracic cage compliance and its ability to absorb mechanical strain. This rigidity, when combined with increased anterior flexion due to vertebral fractures, results in elevated stress forces on the sternum. Such conditions can predispose vulnerable patients to spontaneous sternal insufficiency fractures ( 2 ). Beyond mechanical changes, several clinical risk factors have been identified in the literature, including female sex, advanced age, osteoporosis, chronic obstructive pulmonary disease, rheumatoid arthritis, and prolonged corticosteroid use ( 3 ). This patient presented multiple of these: female sex, severe osteoporosis, advanced age, a prior course of systemic corticosteroids, and ongoing inhaled corticosteroid therapy. The convergence of these factors, alongside the recent vertebral fracture, created an ideal context for the occurrence of a spontaneous sternal fracture. In this case, the clinical presentation mimicked acute coronary syndrome, with chest pain, tachycardia, hypertension, and diaphoresis. This emphasizes the need to consider sternal fractures in the differential diagnosis of chest pain in elderly osteoporotic patients—especially when pain is reproducible on palpation ( 1 ). Imaging was essential for the diagnosis. While standard radiographs may lack sensitivity, thoracic CT—used in our case—allows for precise visualization of sternal fractures and helps exclude alternative diagnoses. MRI can be useful in equivocal cases or to assess complications such as bone marrow edema or retrosternal hematomas ( 4 , 5 ). The case also raises important points about osteoporosis management following denosumab therapy. Denosumab is a monoclonal antibody targeting RANKL, a key mediator of osteoclast activity, and is widely used in the treatment of osteoporosis. Its antiresorptive effect is potent but reversible, which explains the sharp rebound in bone turnover markers and rapid bone loss upon discontinuation. This phenomenon is associated with a significantly increased risk of vertebral fractures, often multiple and occurring within months of the last injection ( 6 – 8 ). In this patient, no consolidation therapy with zoledronic acid was administered after denosumab discontinuation, reflecting a common oversight in clinical practice. A contributing factor may be the overestimation of dental contraindications, leading to avoidance of bisphosphonate therapy. Indeed, concerns about osteonecrosis of the jaw are frequently overestimated; recent data indicate that its absolute risk in osteoporotic patients is very low, particularly with oral or intermittent intravenous bisphosphonates ( 9 ). In contrast, delaying or withholding antiresorptive treatment may result in a substantially higher risk of disabling and preventable fractures. For pain management, topical lidocaine provided excellent relief of the sternal fracture and should be considered an effective and underutilized option for managing superficial localized bone pain in frail elderly patients. Compared to systemic analgesics, topical lidocaine has the advantage of minimal systemic absorption, reducing the risk of adverse effects, which is particularly important in elderly patients with multiple comorbidities. Treatment of the underlying osteoporosis is essential to prevent subsequent fractures. Conclusion Sternal insufficiency fractures, although rare, should be considered in elderly osteoporotic patients presenting with acute anterior chest pain—especially those with vertebral fractures or thoracic deformities. This case underscores the importance of ensuring timely zoledronic acid administration following denosumab discontinuation, even in the presence of relative contraindications such as dental procedures. Clinical vigilance and proactive risk-benefit analysis can prevent avoidable and painful complications in this vulnerable population. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and materials The data that support the findings of this study are derived from the patient's electronic medical record and are not publicly available due to confidentiality constraints. However, anonymized data are available from the corresponding author upon reasonable request and within the limits of patient privacy protection. Competing interests The authors declare that they have no competing interests. Funding No funding was received for this study. Authors' contributions MU wrote the initial draft of the manuscript. MM reviewed and revised the manuscript critically for important intellectual content. Both authors read and approved the final manuscript. Acknowledgements Not applicable. References Ong CJ, Mourad T, Weiss P, Martin R, Palaparty G, Allam E. Sternal stress fracture presenting as acute chest pain. Radiol Case Rep. 2023;18(12):4435–8. 10.1016/j.radr.2023.09.029 . Cajiao K, Florez H, Peris P. Sternal Stress Fractures: An Unusual Cause of Chest Pain in Patients With Osteoporosis. JCR: Journal of Clinical Rheumatology. janv. 2022;28(1):e286. Abrahamsen SØ, Madsen CF. Atraumatic sternum fracture. Case Rep 17 oct. 2014;2014:bcr2014206683. Kompel AJ, Roemer FW, Murakami AM, Diaz LE, Crema MD, Guermazi A. MR imaging of nontraumatic musculoskeletal emergencies. Radiographics. 2015;35(6):1765–87. 10.1148/rg.2015150051 . Fayad LM, Bluemke DA, Fishman EK. Musculoskeletal imaging with computed tomography and magnetic resonance imaging: when is computed tomography the study of choice? Curr Probl Diagn Radiol. 2005;34(6):220–37. 10.1067/j.cpradiol.2005.08.003 . Miller PD, et al. Effects of denosumab on bone turnover markers after treatment and after discontinuation. J Clin Endocrinol Metab. 2008;93(12):4216–25. Tsourdi E, et al. Fracture risk and management of discontinuation of denosumab therapy: a systematic review. Bone. 2017;105:11–7. Anastasilakis AD, et al. Rebound-associated vertebral fractures after discontinuation of denosumab therapy. Eur J Endocrinol. 2017;177(6):R165–83. Kim SH, et al. Incidence of and risk for osteonecrosis of the jaw in Korean osteoporosis patients treated with bisphosphonates: A nationwide cohort-study. Bone. 2021;143:115650. 10.1016/j.bone.2020.115650 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 May, 2026 Reviewers agreed at journal 12 May, 2026 Reviewers agreed at journal 22 Jun, 2025 Reviews received at journal 18 Jun, 2025 Reviewers agreed at journal 15 Jun, 2025 Reviewers invited by journal 13 Jun, 2025 Editor invited by journal 23 May, 2025 Editor assigned by journal 12 May, 2025 Submission checks completed at journal 12 May, 2025 First submitted to journal 06 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6605151","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":471444495,"identity":"b78db556-dec3-4e9d-8ad5-5533697e351d","order_by":0,"name":"Mayalen Uthurriague","email":"data:image/png;base64,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","orcid":"","institution":"National Reference Center for Systemic Autoimmune Rare Diseases RESO, Hôpital Pellegrin, Bordeaux University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Mayalen","middleName":"","lastName":"Uthurriague","suffix":""},{"id":471444496,"identity":"42b17a15-fab4-4dbf-bcb5-5671c2f8796d","order_by":1,"name":"Maëva Masson","email":"","orcid":"","institution":"Toulouse University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Maëva","middleName":"","lastName":"Masson","suffix":""}],"badges":[],"createdAt":"2025-05-06 16:38:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6605151/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6605151/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84695016,"identity":"2f69e476-3c7e-4a69-b19b-40f6737260b6","added_by":"auto","created_at":"2025-06-16 10:27:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":345065,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6605151/v1/70dd8360-d748-4902-bf5f-528b483c4d9a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Domino Effect: When Vertebral Fractures Lead to Sternal Pain ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSternal fractures are typically the result of direct trauma, most commonly occurring in motor vehicle accidents or high-energy falls. However, spontaneous or insufficiency sternal fractures are an increasingly recognized clinical entity in elderly patients with advanced osteoporosis. These fractures can present with acute chest pain that mimics cardiac conditions, posing diagnostic challenges (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The exact incidence of insufficiency sternal fractures remains poorly documented, as they are often unrecognized or confused with other pathologies.\u003c/p\u003e \u003cp\u003eWe present here a rare case of spontaneous sternal fracture in an elderly woman with severe osteoporosis, that occurred shortly after a thoracic vertebral fracture, illustrating the cascade of complications that can arise from uncontrolled osteoporosis and denosumab discontinuation without appropriate consolidation therapy.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMedical History\u003c/h2\u003e \u003cp\u003eAn 81-year-old woman was admitted for the management of a highly painful osteoporotic compression fracture of the fifth thoracic vertebra (T5).\u003c/p\u003e \u003cp\u003eHer medical history included hypertension, long-standing asthma, degenerative thoracolumbar scoliosis, an unclassified inflammatory arthritis diagnosed in 2014 (currently in remission), and osteoporosis. The diagnosis of osteoporosis was made in 2015 following a low-energy distal radius fracture.\u003c/p\u003e \u003cp\u003eContributing factors included systemic corticosteroid use in 2014 (4-month tapered course), and ongoing treatment with inhaled corticosteroids for asthma. In contrast, she had no history of early menopause, low body mass index, tobacco use, or excessive alcohol intake. She had undergone hormone replacement therapy for 10 years after menopause. She had regular monthly vitamin D supplementation and a calcium-rich diet (2\u0026ndash;3 dairy products per day)\u003c/p\u003e \u003cp\u003eShe was initially treated with oral bisphosphonates (risedronate 35 mg once weekly) for four years, but this was discontinued in 2019 due to poor gastrointestinal tolerance (persistent nausea). She was then switched to denosumab (60 mg subcutaneously every six months) for three years. The last injection was given in January 2022. Post-denosumab consolidation therapy with intravenous zoledronic acid was not administered due to recent dental issues.\u003c/p\u003e \u003cp\u003eBone mineral density (BMD) assessment in May 2022 showed improvement, with a T-score of -2.1 at the lumbar spine and \u0026minus;\u0026thinsp;2.5 at the femoral neck. BMD had steadily improved over time: T-score at the spine had increased from \u0026minus;\u0026thinsp;3.1 in 2016 to -2.7 in 2018 and then to -2.1 in 2022. The femoral neck T-score remained stable at -2.5.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCurrent Clinical Presentation\u003c/h3\u003e\n\u003cp\u003eIn October 2022, nine months after her last denosumab injection, the patient developed acute mid-thoracic pain during minimal exertion (bending to pick up an object). Spine radiography revealed an osteoporotic compression fracture of the fifth thoracic vertebra (T5).\u003c/p\u003e \u003cp\u003eThe intensity of the pain and resulting functional impairment made it impossible for the patient to remain at home, leading to hospital admission for pain management.\u003c/p\u003e \u003cp\u003eOn admission, laboratory workup showed a hemoglobin level of 12.5 g/dL with normocytic indices, leukocytes at 7.4 G/L, and platelet count at 305 G/L. Renal function was preserved (CKD-EPI eGFR 85 mL/min/1.73m\u0026sup2;), with no abnormalities in the electrolyte panel or calcium-phosphate balance (calcium 2.34 mmol/L, phosphate 1.1 mmol/L). Liver enzymes were within reference range. Thyroid-stimulating hormone (TSH) was 0.72 \u0026micro;U/mL, parathyroid hormone (PTH) was 10 pg/mL, and 25-hydroxy-vitamin D was measured at 35 ng/mL. Serum protein electrophoresis was unremarkable. C-terminal telopeptides of type I collagen (CTX) were not measured.\u003c/p\u003e\n\u003ch3\u003eHospital Course\u003c/h3\u003e\n\u003cp\u003eLess than 24 hours after admission for the vertebral fracture, the patient experienced sudden-onset anterior chest pain while moving from a seated position, rated 8/10 on the numerical scale. The pain was aggravated by respiratory movements and sternal palpation. It was accompanied by tachycardia (102 beats/minute), hypertension (204/96 mmHg), and diaphoresis. Physical examination revealed focal tenderness over the sternum, without crepitus or visible deformity. Cardiac and pulmonary auscultation were unremarkable, and the ECG showed sinus rhythm with no signs of ischemia, ruling out acute coronary syndrome.\u003c/p\u003e \u003cp\u003eA chest computed tomography (CT) scan was performed. Sagittal reconstructions revealed a spontaneous transverse sternal fracture without significant displacement (\u003cb\u003eFigure A\u003c/b\u003e,), as well as the previously identified T5 vertebral compression fracture (\u003cb\u003eFigure B\u003c/b\u003e). The vertebral collapse had further worsened her pre-existing thoracic kyphosis. This postural imbalance, combined with her advanced age and severe osteoporosis, was identified as the likely combination of contributing factors for the sternal insufficiency fracture.\u003c/p\u003e\n\u003ch3\u003eManagement\u003c/h3\u003e\n\u003cp\u003eShe was treated symptomatically with 5% lidocaine patches applied locally to the painful sternal area (one patch every 12 hours), which resulted in rapid and substantial pain relief.\u003c/p\u003e \u003cp\u003eZoledronic acid was administered intravenously (5 mg single infusion) the day following the discovery of the sternal fracture, without complications. Vitamin D supplementation was continued.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case illustrates a spontaneous sternal insufficiency fracture in an elderly woman with severe osteoporosis, occurring within 24 hours of hospitalization for an osteoporotic vertebral compression fracture. The close temporal association strongly suggests a biomechanical relationship between the two events.\u003c/p\u003e \u003cp\u003eVertebral collapse with resulting postural changes\u0026mdash;particularly increased thoracic kyphosis\u0026mdash;can shift mechanical loads to the anterior thoracic structures, increasing the risk of non-traumatic sternal fractures. In the aging population, progressive ossification of costal cartilages reduces thoracic cage compliance and its ability to absorb mechanical strain. This rigidity, when combined with increased anterior flexion due to vertebral fractures, results in elevated stress forces on the sternum. Such conditions can predispose vulnerable patients to spontaneous sternal insufficiency fractures (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBeyond mechanical changes, several clinical risk factors have been identified in the literature, including female sex, advanced age, osteoporosis, chronic obstructive pulmonary disease, rheumatoid arthritis, and prolonged corticosteroid use (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This patient presented multiple of these: female sex, severe osteoporosis, advanced age, a prior course of systemic corticosteroids, and ongoing inhaled corticosteroid therapy. The convergence of these factors, alongside the recent vertebral fracture, created an ideal context for the occurrence of a spontaneous sternal fracture.\u003c/p\u003e \u003cp\u003eIn this case, the clinical presentation mimicked acute coronary syndrome, with chest pain, tachycardia, hypertension, and diaphoresis. This emphasizes the need to consider sternal fractures in the differential diagnosis of chest pain in elderly osteoporotic patients\u0026mdash;especially when pain is reproducible on palpation (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImaging was essential for the diagnosis. While standard radiographs may lack sensitivity, thoracic CT\u0026mdash;used in our case\u0026mdash;allows for precise visualization of sternal fractures and helps exclude alternative diagnoses. MRI can be useful in equivocal cases or to assess complications such as bone marrow edema or retrosternal hematomas (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe case also raises important points about osteoporosis management following denosumab therapy. Denosumab is a monoclonal antibody targeting RANKL, a key mediator of osteoclast activity, and is widely used in the treatment of osteoporosis. Its antiresorptive effect is potent but reversible, which explains the sharp rebound in bone turnover markers and rapid bone loss upon discontinuation. This phenomenon is associated with a significantly increased risk of vertebral fractures, often multiple and occurring within months of the last injection (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In this patient, no consolidation therapy with zoledronic acid was administered after denosumab discontinuation, reflecting a common oversight in clinical practice.\u003c/p\u003e \u003cp\u003eA contributing factor may be the overestimation of dental contraindications, leading to avoidance of bisphosphonate therapy. Indeed, concerns about osteonecrosis of the jaw are frequently overestimated; recent data indicate that its absolute risk in osteoporotic patients is very low, particularly with oral or intermittent intravenous bisphosphonates (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In contrast, delaying or withholding antiresorptive treatment may result in a substantially higher risk of disabling and preventable fractures.\u003c/p\u003e \u003cp\u003eFor pain management, topical lidocaine provided excellent relief of the sternal fracture and should be considered an effective and underutilized option for managing superficial localized bone pain in frail elderly patients. Compared to systemic analgesics, topical lidocaine has the advantage of minimal systemic absorption, reducing the risk of adverse effects, which is particularly important in elderly patients with multiple comorbidities.\u003c/p\u003e \u003cp\u003eTreatment of the underlying osteoporosis is essential to prevent subsequent fractures.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSternal insufficiency fractures, although rare, should be considered in elderly osteoporotic patients presenting with acute anterior chest pain\u0026mdash;especially those with vertebral fractures or thoracic deformities. This case underscores the importance of ensuring timely zoledronic acid administration following denosumab discontinuation, even in the presence of relative contraindications such as dental procedures. Clinical vigilance and proactive risk-benefit analysis can prevent avoidable and painful complications in this vulnerable population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are derived from the patient's electronic medical record and are not publicly available due to confidentiality constraints. However, anonymized data are available from the corresponding author upon reasonable request and within the limits of patient privacy protection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMU wrote the initial draft of the manuscript. MM reviewed and revised the manuscript critically for important intellectual content. Both authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOng CJ, Mourad T, Weiss P, Martin R, Palaparty G, Allam E. Sternal stress fracture presenting as acute chest pain. Radiol Case Rep. 2023;18(12):4435\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.radr.2023.09.029\u003c/span\u003e\u003cspan address=\"10.1016/j.radr.2023.09.029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCajiao K, Florez H, Peris P. Sternal Stress Fractures: An Unusual Cause of Chest Pain in Patients With Osteoporosis. JCR: Journal of Clinical Rheumatology. janv. 2022;28(1):e286.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbrahamsen S\u0026Oslash;, Madsen CF. Atraumatic sternum fracture. Case Rep 17 oct. 2014;2014:bcr2014206683.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKompel AJ, Roemer FW, Murakami AM, Diaz LE, Crema MD, Guermazi A. MR imaging of nontraumatic musculoskeletal emergencies. Radiographics. 2015;35(6):1765\u0026ndash;87. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1148/rg.2015150051\u003c/span\u003e\u003cspan address=\"10.1148/rg.2015150051\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFayad LM, Bluemke DA, Fishman EK. Musculoskeletal imaging with computed tomography and magnetic resonance imaging: when is computed tomography the study of choice? Curr Probl Diagn Radiol. 2005;34(6):220\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1067/j.cpradiol.2005.08.003\u003c/span\u003e\u003cspan address=\"10.1067/j.cpradiol.2005.08.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller PD, et al. Effects of denosumab on bone turnover markers after treatment and after discontinuation. J Clin Endocrinol Metab. 2008;93(12):4216\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsourdi E, et al. Fracture risk and management of discontinuation of denosumab therapy: a systematic review. Bone. 2017;105:11\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnastasilakis AD, et al. Rebound-associated vertebral fractures after discontinuation of denosumab therapy. Eur J Endocrinol. 2017;177(6):R165\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim SH, et al. Incidence of and risk for osteonecrosis of the jaw in Korean osteoporosis patients treated with bisphosphonates: A nationwide cohort-study. Bone. 2021;143:115650. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bone.2020.115650\u003c/span\u003e\u003cspan address=\"10.1016/j.bone.2020.115650\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6605151/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6605151/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSternal insufficiency fractures remain an uncommon but increasingly recognized condition in elderly patients with advanced osteoporosis. They typically manifest as acute anterior chest pain, which can closely mimic cardiac pathology, leading to potential delays in diagnosis if not investigated with appropriate imaging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe describe the case of an 81-year-old woman with a history of severe osteoporosis who was admitted for management of a painful osteoporotic compression fracture at the fifth thoracic vertebra (T5). Her osteoporosis had previously been managed with oral bisphosphonates, followed by three years of denosumab therapy. However, no antiresorptive consolidation therapy was administered after her last denosumab injection, given nine months prior, due to recent dental issues.\u003c/p\u003e\n\u003cp\u003eWithin 24 hours of admission, the patient developed sudden-onset anterior chest pain while moving from a seated position. The pain was reproducible on palpation over the sternum. A chest CT scan revealed a spontaneous, non-displaced transverse sternal fracture. The recent vertebral collapse had further accentuated her thoracic kyphosis, likely increasing mechanical stress on the sternum and contributing to the fracture. Management included local application of lidocaine patches, which provided effective pain relief, along with a single intravenous dose of zoledronic acid for osteoporosis consolidation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case underscores the importance of considering sternal insufficiency fractures in elderly patients with osteoporosis who present with chest pain, especially in the context of recent vertebral fractures or postural deformities. It also highlights the potential complications associated with denosumab discontinuation when not followed by appropriate consolidation therapy. Finally, it draws attention to the utility of topical lidocaine as a simple, well-tolerated option for localized bone pain in frail, elderly patients.\u003c/p\u003e","manuscriptTitle":"The Domino Effect: When Vertebral Fractures Lead to Sternal Pain ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 10:11:00","doi":"10.21203/rs.3.rs-6605151/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-16T15:48:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152192206382966289757097526478807850467","date":"2026-05-12T15:10:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277047883399357165711004063364818888124","date":"2025-06-22T07:15:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-18T13:11:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"179661072757354590150736129646469727661","date":"2025-06-16T03:31:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-13T06:26:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-23T06:58:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-12T14:52:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-12T14:51:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-05-06T16:30:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b9fe65ca-dc05-45b7-b234-5bbba9a1268c","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-16T15:48:45+00:00","index":88,"fulltext":""},{"type":"reviewerAgreed","content":"152192206382966289757097526478807850467","date":"2026-05-12T15:10:03+00:00","index":84,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-16T10:11:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-16 10:11:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6605151","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6605151","identity":"rs-6605151","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}