osteoporosis

• Osteoporosis is the most common metabolic bone disease

in the United States and can result in devastating physical,
psychosocial, and economic consequences.
• It is often overlooked and undertreated, however, in large
part because it is clinically silent before manifesting as
fracture.
Osteoporosis. Lateral radiograph demonstrates multiple
osteoporotic vertebral compression fractures.
Kyphoplasty has been performed at one level.
• Osteoporosis, a chronic, progressive disease of
multifactorial It has been most
recognized
etiology. in elderly whitefrequently
women, although it does occur
in both sexes, all races, and all age groups. Screening at-risk
populations is essential.
• Osteoporosis is a systemic skeletal disease characterized by
low bone mass and microarchitectural deterioration of
bone tissue, with a consequent increase in bone fragility.
The disease often does not become clinically apparent until
a fracture occurs
Osteoporosis of the spine. Observe the Osteoporosis of the spine. Note the
considerable reduction in overall lateral wedge fracture in L3 and the
vertebral bone density and note the central burst fracture in L5. The patient
lateral wedge fracture of L2. had suffered a recent fall.
 Pathophysiology
• Alterations in bone formation and resorption
• Estrogen deficiency
Estrogen deficiency accelerates bone loss in
postmenopausal women
• Aging
Aging is associated with a progressive decline in the supply
of osteoblasts in proportion to their demand causing bone loss.
• Calcium deficiency
Can lead to secondary hyperparathyroidism, which increases
calcium resorption from bone, decreases renal calcium excretion,
and increases renal production of 1,25-dihydroxyvitamin D
• Vitamin D deficiency
Can result in secondary hyperparathyroidism via decreased
intestinal calcium absorption.
• Osteoporotic fractures
Represent the clinical significance of derangements in bone.
• Osteoporosis versus osteomalacia
In osteoporosis, the bones are porous and brittle, whereas in
osteomalacia, the bones are soft. In osteoporosis, the mineral-to-
collagen ratio is within the reference range, whereas in
osteomalacia, the proportion of mineral composition is reduced
relative to organic material content.
Hypogonadal states
Androgen insensitivity
Panhypopituitarism
Anorexia nervosa/bulimia nervosa Premature menopause
Female athlete triad Turner syndrome
Hyperprolactinemia Klinefelter syndrome

Endocrine disorders
Cushing syndrome
Hyperparathyroidis
Diabetes mellitus m Hyperthyroidism
Acromegaly Hypogonadism
Adrenal insufficiency Pregnancy
Estrogen deficiency Prolactinoma
Deficiency states
Calcium deficiency
Magnesium deficiency Gastrectomy
Protein deficiency Malabsorption
Vitamin D deficiency Malnutrition
Bariatric surgery Parenteral nutrition
Celiac disease Primary biliary cirrhosis

Inflammatory diseases
Inflammatory bowel disease
Ankylosing spondylitis Rheumatoid arthritis
Systemic lupus erythematosus
Hematologic and neoplastic disorders

Hemochromatosis
Hemophilia Sickle cell anemia
Leukemia Systemic mastocytosis
Lymphoma Thalassemia
Multiple myeloma Metastatic disease
Medications
Anticonvulsants
Antipsychotic drugs Furosemide
Antiretroviral drugs Glucocorticoids and corticotropin
Aromatase inhibitors Heparin (long term)
Chemotherapeutic/transplant Hormonal/endocrine therapies: gonadotropin-
drugs: cyclosporine, releasing hormone (GnRH) agonists, luteinizing
tacrolimus, platinum hormone-releasing hormone (LHRH)
compounds, analogues, depomedroxyprogesterone,
cyclophosphamide, excessive thyroxine
ifosfamide, high-dose Lithium
methotrexate Selective serotonin reuptake inhibitors (SSRIs)
Miscellaneous
Alcoholism
Amyloidosis Idiopathic scoliosis
Chronic metabolic acidosis Immobility
Congestive heart failure Multiple sclerosis
Depression Ochronosis
Emphysema Organ transplantation
Chronic or end-stage renal disease Pregnancy/lactation
Chronic liver disease Sarcoidosis
HIV/AIDS Weightlessness
 Risk factors
Advanced age (≥50 years) Physical inactivity or immobilization
Female sex Use of certain drugs (eg,
White or Asian ethnicity anticonvulsants, systemic steroids,
Genetic factors, such as a family thyroid supplements, heparin,
history of osteoporosis chemotherapeutic agents, insulin)
Thin build or small stature, eg, body Alcohol and tobacco use
weight less than 127 lb, (57.7 kg) Androgen or estrogen deficiency
Amenorrhea Calcium deficiency
Late menarche Dowager hump
Early menopause
Postmenopausal
state
A potentially useful mnemonic for osteoporotic risk factors is
OSTEOPOROSIS, as follows:
• L O w calcium intake
• S eizure meds (anticonvulsants)
• T hin build
• E thanol intake
• Hyp O gonadism
• P revious fracture
• Thyr O id excess
• R ace (white, Asian)
• O ther relatives with osteoporosis
• S teroids
• I nactivity
• S moking
Epidemiology

• 9.9 million Americans have osteoporosis and an additional

43.1 million have low bone density.
• In the United States, two million fractures are attributed to
osteoporosis annually, with 432,000 hospital admissions,
2.5 million medical office visits and approximately 180,000
nursing home admissions.
• Globally, osteoporosis is by far the most common metabolic
bone disease, estimated to affect over 200 million people
worldwide. An estimated 75 million people in Europe, the
United States, and Japan have osteoporosis.
• Age demographics
• Risk for osteoporosis increases with age as BMD declines.
• Sex demographics
• Women are at a significantly higher risk for osteoporosis.
• Racial demographics
• Osteoporosis can occur in persons of all races and
ethnicities. In general, however, whites (especially of
northern European descent) and Asians are at increased
risk. In particular, non-Hispanic white women and Asian
women are at higher risk for osteoporosis.
Osteoporosis. Lateral radiograph
demonstrates multiple osteoporotic
vertebral compression fractures.
Kyphoplasty has been performed at one
level.
Osteoporosis. Lateral radiograph of the
patient seen in the previous image following
kyphoplasty performed at 3 additional levels.
Signs and symptoms

• Osteoporosis generally does not become clinically apparent until a

fracture occurs.
• Two thirds of vertebral fractures are painless.
• Typical findings in patients with painful vertebral fractures may
include the following:
- The episode of acute pain may follow a fall or minor trauma
-Pain is localized to a specific, identifiable, vertebral level in the mid
thoracic to lower thoracic or upper lumbar spine
-The pain is described variably as sharp, nagging, or dull; movement
may exacerbate pain; in some cases, pain radiates to the abdomen
- Pain is often accompanied by paravertebral muscle spasms
exacerbated by activity and decreased by lying supine
-Patients often remain motionless in bed because of fear of
causing an exacerbation of pain
-Acute pain usually resolves after 4-6 weeks; in the setting of
multiple fractures with severe kyphosis, the pain may
become chronic
Physical Examination

• The physical examination should begin with an inspection

of the patient.
• Height measurement with a stadiometer at each visit may
be useful.
• Examination of active and passive range of motion (ROM)
assists in determining whether spine, hip, wrist, or other
osseous pathology may be present.
• A thorough neurologic examination is essential to rule out
spinal cord and/or peripheral nerve compromise.
Signs of fracture

• Vertebral compression fractures may be demonstrated by a

thoracic kyphosis with an exaggerated cervical lordosis (dowager
hump).
• Acute vertebral fractures may have point tenderness over the
involved vertebrae.
• Hip fractures may have severe pain with ambulation. Also may show
decreased weight-bearing on the fractured side or an antalgic gait
pattern.
• Pubic and sacral fractures may report marked pain with ambulation
and tenderness to palpation, percussion, or both.
• Signs of collagen defects
• Osteoporosis may have physical findings consistent
with the associated collagen disease
• Balance difficulties
• Osteoporosis is known to have decreased balance, possibly
secondary to differences in balance control strategies and
sway amplitude
Hip fractures occur at the upper
end of the thigh bone (femur).
Intracapsular Fracture. This
fracture occurs at the level of the
"neck" of the bone
Diagnosis
• Complete blood count: May reveal anemia
• Serum chemistry levels: Usually normal in persons with
primary osteoporosis
• Liver function tests
• Thyroid-stimulating hormone level: Thyroid dysfunction has
been associated with osteoporosis
• 25-Hydroxyvitamin D level: Vitamin D insufficiency can
predispose to osteoporosis
• Serum protein electrophoresis: Multiple myeloma may be
associated with osteoporosis
Bone mineral density (BMD) measurement is recommended
in the following patients :

• Women age 65 years and older and men age 70 years and
older, regardless of clinical risk factors
• Postmenopausal women and men above age 50–69, based
alpha-hydroxylase
on risk factor profile
• Postmenopausal women and men age 50 and older who
have had an adult-age fracture, to diagnose and determine
the degree of osteoporosis
• Vertebral imaging is recommended for the
following patients:
• All women age 70 and older and all men age 80 and older
whose BMD T-score at the spine, total hip, or femoral neck
is –1.0 or lower
• All women age 65 to 69 and all men age 70-79 whose BMD
T-score at the spine, total hip, or femoral neck is –1.5 or
lower
• Vertebral imaging is also recommended for
postmenopausal women and men age 50 and older with
the following specific risk factors:
• Low-trauma fractures
• Height loss of 1.5 inches (4 cm) or more since peak height at
age 20
• Height loss of 0.8 inches (2 cm) or more since a previously
documented height measurement
• Recent or ongoing long-term glucocorticoid treatment
• Other plain radiography features and recommended as follows:
- Obtain radiographs of the affected area in symptomatic patients
-Lateral spine radiography can be performed in asymptomatic
patients in whom a vertebral fracture is suspected; a scoliosis
series is useful for detecting occult vertebral fractures
-Radiographic findings can suggest the presence of osteopenia,
or bone loss, but cannot be used to diagnose osteoporosis
-Radiographs may also show other conditions, such as
osteoarthritis, disk disease, or spondylolisthesis
Diagnostic Considerations

• Osteomalacia
• Leukemia
• Lymphoma
• Metastases (bony and other)
• Pathologic fractures secondary to bone metastases from
cancer
• Pediatric osteogenesis imperfecta
• Renal osteodystrophy
Differential Diagnoses

• Homocystinuria/Homocysteinemia
• Hyperparathyroidism
• Imaging in Osteomalacia and Renal Osteodystrophy
• Mastocytosis
• Multiple Myeloma
• Paget Disease
• Scurvy
• Sickle Cell Anemia
 Complications
• Vertebral compression fractures often occur with minimal
stress, such as coughing, lifting, or bending.
• Hip fractures are the most devastating and occur most
commonly at the femoral neck and intertrochanteric regions.
• Secondary complications of hip fractures include nosocomial
infections and pulmonary thromboembolism.
• Increased morbidity and mortality secondary to vertebral
compression fractures and hip fractures.
• Spinal deformities and a dowager's hump, and they may lose
1-2 inches of height by their seventh decade of life
Prognosis

The prognosis for osteoporosis is good if bone loss is

detected in the early phases and proper intervention is
undertaken.
• Effect of fractures on prognosis
- Vertebral compression fractures are associated with
increased morbidity and mortality rates.
- Hip fractures, More than 250,000 hip fractures are
attributed to osteoporosis each year, they are associated
with significantly increased morbidity and mortality rates in
men and women.
Osteoporosis workup
• Radiographic findings can suggest the presence of
osteopenia, or bone loss, but cannot be used to diagnose
osteoporosis.
• Osteopenia is suggested by a cortical width that is less than
the medullary width.
• Plain radiography is not as accurate as BMD testing.
Because osteoporosis predominantly affects trabecular
bone rather than cortical bone, radiography does not reveal
osteoporotic changes until they affect the cortical bone.
Intertrochanteric Fracture. Subtrochanteric Fracture. This occurs
even further down the bone and may be
This occurs further down the bone
broken into several pieces.
Dual-Energy X-Ray Absorptiometry
(DXA)
DXA is currently
the criterion
standard for the
evaluation of
BMD.
DXA is used to
calculate BMD
at the lumbar
spine, hip, and
proximal
femur
• DXA provides the patient’s T-score, which is the BMD value
compared with that of control subjects who are at their peak
BMD.
• World Health Organization (WHO) criteria define a normal T-
score value as within 1 standard deviation (SD) of the mean
BMD value in a healthy young adult.
• Values lying farther from the mean are stratified as follows:
- T-score of –1 to –2.5 SD indicates osteopenia
- T-score of less than –2.5 SD indicates osteoporosis
-T-score of less than –2.5 SD with fragility fracture(s) indicates
severe osteoporosis
• DXA also provides the patient’s Z-score, which reflects a value
compared with that of persons matched for age and sex.
• Z-scores adjusted for ethnicity or race should be used in the
following patients:
• Premenopausal women
• Men younger than 50 years
• Children
• Z-score values of –2.0 SD or lower are defined as "below the
expected range for age" and those above –2.0 SD as "within the
expected range for age." The diagnosis of osteoporosis in these
groups should not be based on densitometric criteria alone.
WHO Definition of Osteoporosis Based on BMD Measurements by DXA
Definition Bone Mass Density Measurement T-Score
BMD within 1 SD of the mean
Normal bone density for young adult women T-score ≥ –1

Low bone mass BMD 1–2.5 SD below the mean for T-score between –1
(osteopenia) young-adult women and –2.5
Osteoporosis BMD ≥2.5 SD below the normal mean T-score ≤ –2.5
for young-adult women
BMD ≥2.5 SD below the normal mean
Severe or for young-adult women in a patient
T-score ≤ –2.5 (with
“established who has already experienced ≥1 fragility fracture[s])
” fractures
osteoporosis
Magnetic Resonance Imaging

• Magnetic resonance imaging (MRI) may be useful in

identifying fractures and in the assessment of metabolic
bone disease.
• Using fat-suppression sequences, marrow edema consistent
with fracture may be noted as areas of hypointensity on T1-
weighted images in association with corresponding areas of
hyperintensity on T2-weighted images.
• MRI is a very sensitive modality and is believed by some to
be the diagnostic imaging method of choice in the
detection of acute fractures, such as sacral fractures
An MRI may identify a hip fracture otherwise missed on plain X-ray.
 Prevention of Osteoporosis

• Primary prevention of starts in childhood.

Patients require adequate calcium intake, vitamin D intake, and
osteoporosis
weight-bearing exercise. Beyond this, prevention of
osteoporosis has two components: behavior modification and
pharmacologic interventions.
• The following behaviors should be modified to reduce the risk
of developing osteoporosis:
- Cigarette smoking
- Physical inactivity
- Intake of alcohol, caffeine, sodium, animal protein, and calcium
Patient Education

• Patient education is paramount in the treatment of

osteoporosis.
• Many patients are unaware of the serious consequences of
osteoporosis, including increased morbidity and mortality,
and only become concerned when osteoporosis manifests
in the form of fracture; accordingly, it is important to
educate them regarding these consequences.
• Early prevention and treatment are essential in the
appropriate management of osteoporosis.