A 75 year old female fall in the bathroom. On examination, She has fracture shaft of femur, this occurs due to:
Ans. (a) OsteoporosisRef: Textbook of Orthopedics 4th Ed by John Ebnezar; Page No- 671* Most commonly fracture occurs in postmenopausal women due to osteoporosis.Diagnostic TestingDual-Energy X-ray Absorptiometry (DEXA)* This scan is the gold standard test for osteoporosis. It is very precise for measuring bone density.* Most common site for measuring bone density: Femoral neck and lumbar spine* Indications for bone mineral density measurement:# All women 65 and older.# Postmenopausal women <65 with one or more risk factors for fracture.# Men with risk factors for fracture.* The results are reported as a T-score according to WHO's classification.* The T-score is the bone density compared with what is normally expected in a healthy young adult of the same sex. The T-score is the number of units--standard deviations-- that bone density is above or below the average.Bone Mineral Density T-scoreDiagnosisT-scoreNormalGreater than or equal to 1.0OsteopeniaBetween -1.5 to -2.5Osteoporosis>=-2.5Severe osteoporosis>=-2.5 and fragility fracture* T-scores are used in all postmenopausal and perimenopausal women, and in men over age 50.* In all other patients (including premenopausal women), z-scores are used.* The Z-score is the number of standard deviations above or below what is normally expected for someone of the same age, sex, weight, and ethnic or racial origin.* Z-score <-2 may suggest that something other than aging is causing abnormal bone loss (consider drugs causing osteoporosis such as corticosteroids).24-hour Urine Hydroxyproline* Calcium loss is assessed with a 24-hour urine hydroxyproline or NTX (N-telopeptide, a bone breakdown product).Rule out secondary causes* Check phosphorus, alkaline phosphatase, TSH, vitamin D, free PTH, creatinine, CBC.Treatment* First-line therapy is bisphosphonates or denosumab.* Bisphosphonates (e.g., alendronate, risedronate, ibandronate, zoledronate) acts by inhibiting osteoclast mediated bone resorption by mediating osteoclast apoptosis.* Zoledronate is the most potent bisphosphonate and it is the drug of choice for treatment and prophylaxis of osteoporosis. The dose 2-5mg/ Year.* Alendronate is the drug of choice for treatment of osteoporosis caused by long term glucocorticoid therapy.* Denosumab is an anti-RANK ligand antibody that acts by inhibiting stimulation of osteoclasts to form ruffled border osteoclast. It is given by subcutaneous route of dose of 60mg every six months for 3-5 years for treatment and prophylaxis of osteoporosis. And its efficacy is comparable to bisphosphonates.* Repeat the bone densitometry at 2 years. If there is continued bone loss, move to these:* Selective estrogen receptor modulators (SERMs) are second-line agents that increase bone density.* Raloxifene and bazedoxifene inhibits bone reabsorption and are treatment and prophylaxis of postmenopausal osteoporosis.* Raloxifene is only effective in case of vertebral fractures. Raloxifene also decrease the incidence of breast cancer and MI.* Teriparatide and abaloparatide are PTH analogs that activate osteoblasts for bone matrix synthesis that augments bone formation. It is used when bisphosphonates fail.* Calcitonin is a third-line therapy.
Osteoporosis
Osteopetrosis
Paget's disease
Metastasis
Metabolic Bone Disease