questions 6

Osteoporosis

Topic updated on 09/29/17 11:21pm

Overview
 

 
Snapshot
  • A 67-year-old woman presents to the emergency department after falling while walking down the stairs of her home. She landed on her rear on a carpeted floor and denies hitting her head. She experienced severe pain in her right hip after the fall and is unable to bear weight on the affected side. Menopause began 17 years ago. She has smoked 1-pack of cigarettes for the past 40 years. On physical exam, her right leg is shortened, adducted, and externally rotated. Laboratory testing is unremarkable.
Introduction
  • Clinical definition
    • decreased bone mass (osteopenia) that significantly increases the patient's risk of fracture
  • Epidemiology
    • incidence
      • most common types of osteoporosis are
        • post-menopausal
        • senile
    • risk factors
      • post-menopausal women
      • being ≥ 65 years of age
      • people of Caucasian and Asian descent
      • lifestyle factors such as
        • poor physical activity
        • vitamin D deficiency and poor calcium intake
        • smoking
        • alcohol use disorder
      • medications such as
        • warfarin, lithium, proton pump inhibitors, and glucocorticoids
      • hyperparathyroidism
      • hyperthyroidism
      • multiple myeloma
      • malabsorption syndromes
  • Pathogenesis
    • in young adulthood, peak bone mass is achieved and this is determined by a number of factors (e.g., genetics)
      • after this peak bone mass is attained, there is a small decrease in bone formation with every cycle of bone remodeling
        • senile osteoporosis
          • osteoblasts have their biosynthetic and proliferative ability reduced with age
        • poor physical activity
          •  mechanical force on bone stimulates bone remodeling
            • athletes have increased bone density
          • decreased physical activity results in bone loss
        • decreased estrogen levels
          • such as in menopause, decreased estrogen levels increase bone resportion and formation
            • however, the rate of formation is less than resorption resulting in a net bone loss
            • increased osteoclast activity is significant in areas of bone with large surface area
              • such as the vertebral bodies, leading to vertebral compression fractures 
        • there is trabecular and cortical bone loss 
  • Prognosis
    • generally good if detected early and appropriately managed
Presentation
  • Symptoms
    • fractures (e.g., vertberal and hip), otherwise, patients are typically asymptomatic
  • Physical exam
    • may see loss in height
Imaging
  • DEXA
    • indication
      • all women ≥ 65 and all men ≥ 70 years of age
    • notes
      • T-score ≤ -2.5
Studies
  • Labs
    • serum calcium, phosphorus, parathyroid hormone, and alkaline phosphatase are normal
  • Histology
    • histologically normal; however, there is a decreased quantity of normal bone
Differential
 
Laboratory Abnormalities in Select Bone Disorders
Etiology
Serum Phosphate
Serum Calcium
Serum Alkaline Phosphatase
Parathyroid Hormone
Osteomalacia / rickets 
  • Decreased
  • Decreased
  • Increased
  • Increased
Osteoporosis  
  • Normal
  • Normal
  • Normal
  • Normal
Osteopetrosis 
  • Normal
  • Normal or decreased
  • Normal
  • Normal
Paget disease of the bone 
  • Normal
  • Normal
  • Elevated
  • Normal
Osteitis fibrosa cystica 
  • Primary
    hyperparathyroidism
    • decreased
  • Secondary
    hyperparathyroidism
    • increased
  • Primary
    hyperparathyroidism
    • increased
  • Secondary
    hyperparathyroidism
    • decreased
  • Primary and secondary hyperparathyroidism
    • increased
  • Primary and secondary hyperparathyroidism
    • increased
Hypervitaminosis D
  • Increased
  • Increased
  • Normal
  • Decreased
 
Treatment
  • Conservative
    • calcium and vitamin D supplementation
    • strength training
    • smoking cessation
  • Medical
    • bisphosphonates
      • indication
        • first-line for pharmacologic therapy in osteoporosis
    • raloxifene 
      • second line therapy for osteoporosis
      • can cause hot flashes and venous thromboembolism
      • does not cause endometrial hyperplasia or increase risk of breast cancer
    • teriparatide
      • indication
        • considered first-line in patients with a very high risk of fracture
Complications
  • Fractures


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Qbank (3 Questions)

TAG
(M3.OR.10) A 61-year-old African-American female presents to her primary care physician with questions about osteoporosis. She recently read an article about osteoporosis and wonders if she should have her DEXA scan. She is currently on hormone replacement therapy. She works as a middle school teacher and has a 25-pack-year smoking history. She has a body mass index (BMI) of 20. Which of the following is a risk factor for osteoporosis in this particular patient that should prompt a DEXA scan? Topic Review Topic

1. Race
2. Smoking history
3. Body-mass index (BMI)
4. Estrogen therapy
5. Occupation

PREFERRED RESPONSE ▶
TAG
(M3.OR.12) A 59-year-old Caucasian female suffered a fracture of her left distal radius after she lost her balance while reaching overhead and fell from standing height. Her left wrist radiographs are shown in Figure A. A follow-up DEXA bone density scan is performed and demonstrates a T-score of -3.5 at the femoral neck and spine. Her medical history is significant for venous thromboembolic disease; she has not had a previous fracture. After open reduction and internal fixation is achieved, which of the following is the best treatment to mitigate this patient's risk of future fragility fractures? Topic Review Topic
FIGURES: A          

1. Raloxifene
2. Activity limitation
3. Alendronate in combination with calcium and vitamin D supplementation
4. Risedronate alone
5. Intranasal calcitonin

PREFERRED RESPONSE ▶
TAG
(M3.OR.12) A 68-year-old woman undergoes a dual-energy X-ray absorptiometry scan to assess bone mineral density. Which of the following is not a risk factor for the development of osteoporosis? Topic Review Topic

1. Alcohol use
2. Steroid use
3. Elevated BMI
4. Smoking
5. Sedentary lifestyle

PREFERRED RESPONSE ▶
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