Chapter 411: Osteoporosis

Osteoporosis is a condition characterized by decreased bone strength with an increase in

fractures. This is due to a loss of bone tissue associated with a deterioration of the
microarchitecture. It occurs in both men and women but is more prevalent among
postmenopausal elderly women. When it comes to fractures the rate of hip and vertebral
fractures are exponential with age, with hip fracture rates doubling every 5 years after the age of
70. In patients with hip fractures, there is a greater incidence of developing DVT and pulmonary
embolism. In vertebral fractures, these are mostly asymptomatic and identified during
radiotherapy, and rarely require hospitalization. Thoracic fractures are more related to lung
disease. Fractures in the humerus and other bones are related to trauma and may have less
threshold for fractures when patients are osteoporotic.

Some independed predictors of fracture include age, family history of osteoporosis, history of
smoking, poor nutrition, menopause, intake of drugs, lack of exercise and chronic diseases

PATHOPHYSIOLOGY

For osteoporosis measurement of bone mass using dual-energy x-ray absorptiometry, single
energy x-ray absorptometry, or ultrasound may be done. Among them, DEXA scans are the
standard. The determinations are done usually of the lumbar spine and hip. T scores are then
utilized to determine the level of bone loss and in osteoporosis it should be -2.5 .

Some indications for bone mineral density imaging include women aged >= 65 or men >/= 70
regardless of clinical factors, younger postmenopausal women, women in menopausal transition
, and men aged 50-69 with clinical risk factors for fracture, adults who have a fracture at or after
the age of 50, and adults with a condition or are taking mediations sich as steroids.
It is notable that the hip is the preferred site of measurement since this has the greatist risk of
fractures in the elderly.

For the approach, we take a careful history and PE to identify the risk factors for osteoporosis,
note for any changes in height, screen for bone mineral density, and if the patient has fractures
we need to make sure this is not caused by the risk factors or underlying malignancy.

Routine labs such as CBC, serum 24-hour urine calcium, renal and hepatic function tests, and
25 (OH)D levels are checked. A bone biopsy may also be done if the consideration is of
metabolic bone disease. This is also combined with metabolic markers which measure the
overall state of the bone remodeling at a single point in time. These are mainly used to check for
treatment response.

In managing patients with osteoporosis it frequently involes the management of acute fractures
as well as the underlying disease. Hip fractures would always require surgical repair.
Depending on the location, severity, and condition of the neighboring joining to the fracture, the
general status of the patient we can then decide if ORIF, hemiarthroplasties, or a total
arthroplasty is necessary. For long bone fractures they may require external or internal fixation .

For acutely symptomatic fractures treatment with analgesics (ie. NSAIDS, acetaminophen,
narcotics) , calcitonin, and percutaneous injection of artificial cement may be done. Bed rest
may also be recommended to reduce mobilization and help in pain management.

Severe pain would typically resolve at the 6-10 week mark and a more chnoic pain might
suggest multiple myeloma or an underlying metastatic disease.

Management of underlying problems such as risk factors, nutritional deficiencies should be

assessed and treated. We should also encourage exercise that are weight bearing in order to
reduce the further bone loss especially in postmenopausal women . Walking may be suggested
as an initial exercise and this should be done 3x a week.

We may also consider pharmacologic agents in order to combat osteoporosis such as

bisphosphonates, calcitonin, denosumab, and teriparatide. Estrogen may also be given to
women with natural or surgical menopause with established osteoporosis. It was seen that there
is a 50% reduction to those women who do supplementary estrogen. In treatment the mainstay
is bisphosphonates which would reduce the risk of vertebral fractures in patients with steroid
intake , and improve bone mass of the spine and hip. Teriparatide may also be use to improve
bone mass and reduce fracture risks as compared to alendronate.

To evaluate our patients it is important tot test the height and muscle strength as well as 24 hrs
urinary calciu. All patients on long-term glucocorticoids should gave a measurement of the bone
mass at both the spine and the hip using DEXA.
Prevention of bone loss can be prevented by using the closest does of glucocorticoids possible
to control the disease, controlling the risk factors and supplementation of adequate calcium and
vitamin d.