Doctor123.org

Osteoporosis, Emergency Medicine

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)