Keywords:

  • 61 y.o lady
  • visited outpatient department for annual checkup
  • menopause – early 50s
  • 5’ 7” & 52 kg
    • BMI: 17 – underweight
    • reduced bone mass?
  • pain over back and hip joints
    • worsening over months
  • reduction in her height
    • compared to previous health checkup reports
  • no history of smoking
  • sister, 60 y.o
    • suffered hip fracture last month over a fall
    • familial history of osteoporosis
  • investigations
    • normal ionized calcium
    • normal total serum albumin
    • normal serum phosphorus
      • rule out osteomalacia
    • normal bone specific alkaline phosphatase
    • serum PTH increased
      • may be compensatory due to initial drop in serum calcium level
      • therefore could be that’s why calcium level is normal now
    • bone mineral density (Dual Energy Xray Absorpiometry)
      • T score very low
      • high risk
    • xray
      • there is a wedge fracture
      • image

Hypothesis

  • Osteoporosis
  • Osteoarthritis
  • Cancer
    • bone metastases
  • TB: Pott’s spine
  • osteomalacia
  • Paget’s disease of the bone
  • Trauma
  • Prolapse intervertebral disc
  • Septic Arthritis
  • Osteitis fibrosa
  • Multiple myelome

Final hypothesis

  • osteoporosis

Extra learning issues:

1) Compare osteoporosis, osteomalacia and osteitis fibrosa

  • Osteoporosis
    • bone mass reduction
  • Osteomalacia
    • osteoid formed
    • but insufficiently mineralized
  • Osteitis fibrosa
    • PTH overproduction
    • uncontrolled bone resorption & replaced by fibrous tissue

2) Risk factors of osteoporosis

  • Hereditary
    • +ve family history
  • Asthenic build
    • body fat supplies oestradiol
      • deficiency of oestradiol will cause bone loss
      • therefore this patient is underweight, could be considered a risk factor
  • Premature menapause/late menarche
  • Hysterectomy
  • Amenorrhea
  • Cigarette/alcohol
  • Dietary
  • Men with hypogonadism
  • Medication
    • Increase bone resoprtion
      • Glucocorticoids
      • Heparin
      • Cyclosporine
      • High dose methotrexate
      • High dose medroxyprogesterone acetate
      • Systemic steroids
        • COPD, lupus, rheumatoid arthritis
      • Anticonvulsants
      • Thyroid supplements
      • Insulin
      • Chemotherpeutic drugs (Cancer)
  • Excessive Vitamin A
  • Immobility

3) Wedge /Compression fracture

Definition: Vertebral body has suffered a crush/wedging injury

  • When doing weight-bearing activities
  • Forces exceed ability of bone to support the load
    • causing font part of the vertebral body to crush forming a wedge shape
  • If entire vertebral body breaks
    • known as burst fracture

4) Surgical intervention for wedge fracture

  • Percutaneous vertebroplasty (PVP)
    • inject methyl methacrylate (cement) into the fractured vertebrae
  • Baloon kyphoplasty
    • vertebrae initially expanded with an inflatable balloon tamp
    • reduced fracture and restores height to the vertebral body
    • balloon then removed and cement is injected into the cavity under lower pressure than that used in PVP
    • reduce risk of cement extravasation
      • as compared to PVP

5) Prevention & treatment of osteoporosis

  • Dietary intake of calcium
  • Avoid smoking & excessive alcohol consumption
  • Oestrogen replacement therapy (HRT)
    • Disadvantages: risk of breast and uterine cancer if long term
    • If contraindicated, give
      • calcitonin
      • biphosphonates
  • Physical therapy
    • strenghten the back extensors
    • regular mild weight bearing exercise for maintenance of bone mass
    • balance training, to prevent fall
  • Medication for bone formation
    • calcium
    • vitamins
  • Orthotics (thoracolumbosacral orthosis)
    • image
    • decrease flexion forces
    • prevent worsening of kyphosis
    • reduce pressure on fracture sites
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Terri is obsessed with making medical school as painless as possible. She studies and compiles medical school notes in a concise, easy-to-understand format. She also enjoys reading contributions by others. She is an investor in sustainability projects. Her ideal weekend is wine tasting and experimenting on bread-making. She has yet to master the art of Sourdough baking.

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