Objective With the development of an aging society in China, the incidence of osteoporotic spinal compression fractures in the elderly is increasing, and the diagnosis and treatment of osteoporotic spinal compression fractures in the elderly is receiving more and more attention. The purpose of this lecture is to analyze how to identify osteoporotic spinal compression fractures as fresh or old by history, X-ray, CT and MRI in elderly patients. Methods A total of 107 patients, 35 men and 73 women, aged 72 years, with osteoporotic spinal compression fractures were diagnosed and treated in outpatient and inpatient settings from April 2006 to August 2010. All patients were asked in the outpatient clinic about any obvious causes such as: history of falls, straining while bending, sneezing, and lifting heavy objects such as flower pots. The nature of spinal pain was asked such as pain in changing position: pain in sitting, pain in standing or pain in lying. The presence or absence of abdominal distension was also recorded. All patients underwent x-ray frontal and lateral examinations of the appropriate areas, CT and MRI liposuppression imaging. The fractures were determined to be fresh or old by performing CT and MRI lipid suppression images in obvious vertebral compression fractures on plain X-ray. Results Only 79 cases (73.8%) of the 107 patients in this group had an obvious cause for the fall, and 28 cases (26.2%) did not find any cause. There were 41 compression fractures of the lumbar spine alone, 49 compression fractures of the thoracic spine, and 17 fractures of both the thoracolumbar spine. 101 patients in about 94% of cases presented with spinal pain on changing positions, such as from lying to sitting or from sitting to standing. There were 28 cases of abdominal distension. All were lumbar compression fractures, and 68% of the lumbar compression fractures. x-ray showed significant vertebral compression fractures of 112 vertebral compression fractures of 89 cases. 79 (70.5%) of the MRI lipid-suppressed image high signal were fresh fractures. The remaining vertebrae were old fractures. Conclusion A significant proportion of osteoporotic spinal compression fractures in the elderly have no clear history of falls, and the presence of spinal pain on changing position is a clinical feature of the disease. The diagnosis of fracture is more important to have CT in addition to X-ray, MRI liposuppression image in order to reduce the missed diagnosis and diagnose the fracture old and new.