OSTEOPOROSIS   75A

A 72-year-old woman presents to the emergency department after falling in her home. She slipped on spilled water in her kitchen. She was unable to get up after her fall and was found on the floor in her kitchen by her son who stopped by after work. She complains of severe right hip pain. Her medical history includes giant cell arteritis, for which she has taken daily prednisone for more than 1 year. On examination, she has bruising over her right hip. Range of motion in her right hip is markedly decreased, with pain on both internal and external rotation. Radiography reveals a hip fracture and probable low bone mass.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Elderly; female sex; long-term glucocorticoid use; fall with fracture of hip; radiograph with low bone mass

How to think through: Osteoporosis is a common underdiagnosed problem. In the absence of screening for osteoporosis, the loss of bone density goes untreated and, as in this case, can lead to fracture. Fractures, in turn, precipitate significant morbidity in elderly adults. This patient is an older woman with a history of chronic corticosteroid use. What are the other major risk factors for osteoporosis that should be explored in her history? (Tobacco use, hyperthyroidism, inflammatory bowel and celiac disease, and premenopausal estrogen deficiency [e.g., eating disorders, hypopituitarism, and premature ovarian failure].) What is the screening test for osteoporosis? (Dual-energy x-ray absorptiometry [DEXA].) Can osteoporosis be diagnosed without DEXA testing? (Yes. An older woman, such the patient in this case, with a “fragility” or “low-trauma” fracture can be considered to have osteoporosis and should be so treated.) How should this patient be treated? (Bisphosphonates are the mainstay. Selective estrogen receptor modulators and parathyroid hormone [PTH] are considered in severe cases or with intolerance to bisphosphonate.) When the decision to treat is unclear, consider the many risk factors for fracture. These include age, prior fracture, family history of fracture, low body mass index, and alcohol use. Clinical formulas such as the FRAX algorithm incorporate these factors, along with the DEXA, to determine the risk of major osteoporotic fracture.

OSTEOPOROSIS   75B

What are the essentials of diagnosis and general considerations regarding osteoporosis?

Essentials of Diagnosis

Fracture propensity of the spine, hip, pelvis, and wrist from demineralization

Serum PTH, calcium, phosphorus, and alkaline phosphatase usually normal

Serum 25-hydroxyvitamin D levels often low as a comorbid condition

General Considerations

Causes approximately 2 million fractures, mainly of the spine and hip, annually in the United States

Morbidity and indirect mortality rates very high

Rate of bone formation is often normal, but the rate of bone resorption is increased

Most common causes include aging, high-dose corticosteroid administration, alcoholism, and sex hormone deficiency; occurs more often in women than men

Osteogenesis imperfecta is caused by a mutation in the gene encoding for type I collagen

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