The Domino Effect: When Vertebral Fractures Lead to Sternal Pain

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.