OSTEOPOROSIS - ORTHOPAEDICS - EASYMEDNOTES 2021

OSTEOPOROSIS 

Osteoporosis is commonest metabolic bone disease. 
osteoporosis is characterised by a reduction in the bone density due to a decrease in the bone mass.
This occurs when the rate of bone resorption exceeds the rate of bone formation.



 CAUSES

Several aetiological factors are present.
Commonest factor in males is senility and in females is menopause.

Causes of generalized osteoporosis :

  • Senility
  • Post-immobilization  example : a bed-ridden patient 
  • Post-menopausal
  • Protein deficiency,  Inadequate intake – old age, illness Malnutrition Malabsorption Excess protein loss (3rd degree burns, CRF etc.) 
  • Endocrine Cushing's disease,  Cushing's syndrome,  Hyperthyroid state 
  • Drug induced Long term steroid therapy, Phenobarbitone therapy.

CLINICAL FEATURES 


  1. Osteoporosis is an asymptomatic disorder unless complications predominantly fractures occur. 
  2. Loss of bone mass leads to loss of strength so that a trauma is sufficient to cause a fracture. 
  3. Dorso-lumbar spine is the most frequent site. 
  4. Pain from these fractures is usually the reason for a person to consult a physician. 
  5. Other fractures whose aetiology has been linked to underlying osteoporosis are Colles' fracture and fracture of the neck of femur.
On examination, A minute loss of height and increased kyphosis due to compression of the anterior part of the vertebral bodies. 

RADIOLOGICAL FEATURES 

Radiological evidence of decreased bone mass is more reliable, but about 30 percent of the bone mass must be lost before it becomes apparent on X-rays.

Following features may be noticed on X-rays:
  •  Loss of vertical height of a vertebra due to collapse. 
  • Cod fish appearance- The disc bulges into the adjacent vertebral bodies so that the disc becomes biconvex. 
  • Ground glass appearance of the bones, conspicuous in bones like the pelvis. 
  • Singh's index - Singh et al. graded osteoporosis into 6 grades based on the trabecular pattern of the femoral neck trabeculae.
  • Metacarpal index and vertebral index are other methods of quantification of osteoporosis.

OTHER INVESTIGATIONS 

Biochemistry:  Serum calcium, phosphates and alkaline phosphatase are within normal limits. Total plasma proteins and plasma albumin may be low.

Densitometry: This is a method to quantify osteoporosis. In this method absorption of photons by the bone calcium is measured. 
  • Two types of bone densitometry are available – ultrasound based and X-ray based. 
  • DEXA scan is an X-ray based bone densitometry, and is the gold standard in the quantification of bone mass.
  •  Neutron activation analysis: In this method, calcium in the bone is activated by neutron bombing, and its activity measured. 
  •  Bone biopsy. 

TREATMENT 

There are no set treatment methods as yet. 
The principle objectives of treatment are alleviation of pain and prevention of fractures. 
Treatment can be divided into medical and orthopaedic. 

Medical treatment: 
  • High protein diet: Many elderly patients suffer from malnutrition. Increasing their protein intake may increase the formation of organic matrix of the bone. 
  • Calcium supplementation: It may be helpful in cases with deficiency of calcium in their diet. 
  • Androgens: These hormones have an anabolic effect on the protein matrix of bone, and in some cases it might decrease symptoms. 
  • Estrogens: Estrogens have been shown to halt the progressive loss of bone mass in postmenopausal osteoporosis. 
  • Vitamin D: This is given, in addition to the above, to increase calcium absorption from the gut. 
  •  Fluoride:  It is supposed to make the crystallinity of the bone greater; thereby making bone resorption slower. 
  • Alandronate: dosage is once in a day, empty stomach. Oesophagitis is a troubling complication. 
  • Calcitonin: Parenteral administration of calcitonin helps in building up the bone mass and also acts as an analgesic.
  • Teriparatide: Anabolic agent increasing osteoblastic new bone formation. 
  • Denosumab, Strontium: Antiresorptive agents. 
Orthopaedic treatment: 

  • Exercises: Weight bearing is a stimulus to bone formation.
 Increased guarded activity would therefore be of benefit to the patient. 
  • Bracing: Prophylactic bracing of the spine by using an ASH brace or Taylor brace may be useful in prevention of pathological fractures in a severely osteoporotic spine

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