Basics
Description
- Overall decrease in skeletal mass, generally diffuse
- Trabecular bone (especially vertebrae and femur) affected more commonly and earlier
- Disease begins in adolescence, but fractures do not usually manifest until age ≥50
- Females affected much more commonly than males, especially after menopause
Etiology
- Overall increase in resorption over formation of new bone
- Advanced age is the most important risk factor
- Inadequate dietary calcium an important factor, especially early in life
- Sedentary lifestyle is a risk factor (weight bearing on bone favors new bone formation)
- Decrease in estrogen with menopause key factor in women
- Other risk factors include long-term steroid use, alcoholism, methotrexate, tobacco use, low body weight
- Familial or hereditary factor may coexist
Although disease appears to start in adolescence, pediatric patients are asymptomatic.
Diagnosis
Signs and Symptoms
- Usually asymptomatic until pathologic fractures occur
- Fractures with insignificant mechanism or recurrent fractures are hallmark
- Vertebral column most commonly involved
- Multiple compression fractures of vertebral column often lead to kyphosis and scoliosis
- Hip fractures (femoral neck and intertrochanteric fractures) also common
History
- A suspected fracture with a relatively minor mechanism or a history of multiple fractures suggests osteoporosis.
- A family history of osteoporosis is an important risk factor
Physical Exam
Exam findings are related to the acute fracture rather than the disease itself.
Essential Workup
- Fracture without significant mechanism and identification of risk factors is most important
- Careful neurovascular exam distal to femur or other extremity fracture
- Rectal tone and postvoid residual should be determined in patients with vertebral fractures
- Radiographs of suspected fracture may show osteopenia (late finding in disease)
- Spine films may show old compression fractures
- CT scan should be performed to better evaluate vertebral fractures:
- Retropulsion, spinal canal compromise is not always apparent on plain films.
- Make sure CT cuts extend full level above and below injuries on spine radiographs.
Diagnosis Tests & Interpretation
Lab
Serum chemistries " such as calcium, parathyroid hormone, and alkaline phosphatase " may help differentiate this from other illnesses.
Imaging
- Plain films can identify fractures; however, age of each fracture may be difficult to determine
- Bone scan or CT can help determine age of fractures, especially in spine
Diagnostic Procedures/Surgery
Bone densitometry can provide prognostic information and help guide therapy. Dual-energy x-ray absorptiometry with BMD T-score ≤ " 2.5: Osteoporosis.
Differential Diagnosis
- Multiple myeloma or other metastatic tumor
- Osteogenesis imperfecta (usually apparent in childhood)
- Hyperparathyroidism
- Other demineralizing bone diseases
Treatment
Pre-Hospital
Cautions:
- Obtain pre-hospital information on mechanism to help diagnose pathologic fracture
- Avoid aggressive manipulation or movement of patient, as this may exacerbate bony injury
Initial Stabilization/Therapy
Immobilize fractures
Ed Treatment/Procedures
- Fractures are treated with expectation of delayed or incomplete healing
- Prevention is far more effective than treatment
- Long-term therapy is beneficial (see Medication)
- Use of orthotic back braces and vests should be arranged in conjunction with orthopedic spine consultation
- Exercise is also helpful
- Balance must be achieved between osteoporosis risk and steroid or methotrexate therapy
Medication
- Alendronate: 10 mg/d or 70 mg weekly, alternative is risedronate 5 mg/d, 35 mg weekly, or 150 mg monthly
- Zoledronic acid: 5 mg IV yearly
- Raloxifene (selective estrogen receptor modulator): 60 mg PO QD
- Calcium: 1,200 mg daily (total of diet + supplement)
- Vitamin D: 800 IU/d
- Calcitonin: Nasal spray 200 IU/d
- Denosumab (monoclonal antibody): 60 mg SC every 6 mo
- Parathyroid hormone 1 " 34: 20 Όg SC daily
- Estrogen: 0.625 mg/d (with or without medroxyprogesterone)
Ensure adequate calcium in diet from early age.
Follow-Up
Disposition
Admission Criteria
- Per normal orthopedic protocols, with special considerations for age and social situation
- Compression fractures are generally stable, but possibility of burst fracture with cord compression must be ruled out.
- Any cervical fracture or fracture with neurologic symptoms requires admission with emergent consultation with neurosurgery or orthopedics
- Admission may be necessary for pain control and because of decreased ambulation
Discharge Criteria
- Per normal orthopedic protocols with special considerations for age and social situation
- Patients with minimal injuries, able to care for themselves at home or with appropriate assistance, and adequate postoperative pain control may be discharged with orthopedic follow-up
Issues for Referral
Orthopedic referral is driven by the acute injury.
Follow-Up Recommendations
- Follow-up is generally driven by the acute injuries
- Follow-up with the primary physician should be instituted to encourage treatment and monitoring of the disease to prevent recurrent fractures
Pearls and Pitfalls
- A history of recurrent fractures, particularly with a low-energy mechanism, suggests the possibility of osteoporosis
- Reduced bone density on plain radiographs is highly suggestive and warrants referral back to the PCP for further workup and treatment
- Bisphosphonates are 1st-line therapy for treatment
Additional Reading
- Robbins J, Aragaki AK, Kooperberg C, et al. Factors associated with 5-year risk of hip fracture in postmenopausal women. JAMA. 2007;298(20):2389 " 2398.
- Silverman S, Christiansen C. Individualizing osteoporosis therapy. Osteoporos Int. 2012;23:797 " 809.
- Solomon DH, Polinski JM, Stedman M, et al. Improving care of patients at-risk for osteoporosis: A randomized controlled trial. J Gen Intern Med. 2007;22:362 " 367.
- Tosteson AN, Melton LJ 3rd, Dawson-Hughes B, et al. Cost-effective osteoporosis treatment thresholds: The United States perspective. Osteoporos Int. 2008;19:437 " 447.
- Unnanuntana A, Gladnick BP, Donnelly E, et al. The assessment of fracture risk. J Bone Joint Surg Am. 2010;92(3):743 " 753.
See Also (Topic, Algorithm, Electronic Media Element)
Specific Orthopedic Injuries.
Codes
ICD9
- 733.00 Osteoporosis, unspecified
- 733.01 Senile osteoporosis
- 733.09 Other osteoporosis
- 733.03 Disuse osteoporosis
- 733.02 Idiopathic osteoporosis
- 733.0 Osteoporosis
ICD10
- M80.08XA Age-rel osteopor w current path fracture, vertebra(e), init
- M81.0 Age-related osteoporosis w/o current pathological fracture
- M81.8 Other osteoporosis without current pathological fracture
- M80.059A Age-rel osteopor w current path fracture, unsp femur, init
SNOMED
- 64859006 Osteoporosis (disorder)
- 18040001 Senile osteoporosis
- 32369003 Menopausal osteoporosis (disorder)
- 53174001 Disuse osteoporosis
- 203438009 Vertebral osteoporosis (disorder)
- 3345002 Idiopathic osteoporosis
- 390833005 Osteoporosis due to corticosteroids (disorder)