This review gives a practical guide to the investigation and management of osteoporotic vertebral compression fractures. With an ageing population, the burden of disease and health system costs attributable to this common injury continue to rise. This article outlines the epidemiology, clinical and radiological assessment of vertebral compression fractures, and key decisions that must be made in their management. It reviews the indications and evidence for conservative vs operative treatment, discusses the rationale for vertebroplasty, kyphoplasty and spinal stabilization, and looks at outcomes in this vulnerable patient population. It also reviews key evidence underlying decision making including National Institute for Health and Care Excellence guidelines.