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
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)
- decrease flexion forces
- prevent worsening of kyphosis
- reduce pressure on fracture sites
