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Osteoporosis

Osteoporosis is a disease of bone in which bone mineral density (BMD) is reduced and bone microarchitecture is disrupted. Osteoporotic bones are susceptible to fracture. It is defined according to the bone mineral density as measured by DEXA: a BMD of 2.5 standard deviations below the peak bone mass (20-year-old person standard) is indicative of osteoporosis. While treatment modalities are becoming available, prevention is still the most important way to reduce fracture. Due to its hormonal component, more women suffer from osteoporosis than men. more...

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Signs and symptoms

Clinical picture

Osteoporotic fractures are those that occur under slight amount of stresses that would not normally lead to fractures in nonosteoporotic people. Typical fractures occur in the vertebral column, hip and wrist. Collapse of vertebrae ("compression fracture") leads to chronic pain, characteristic bent stature, and decreased pulmonary function (ability to breathe) while the fractures of the long bones acutely impair mobility and may require surgery. Hip fracture, in particular, carries a poor prognosis.

While osteoporosis may occur in men, the problem is overwhelmingly prevalent in postmenopausal women.

Risk factors

Risk factors for osteoporotic fracture can be split between modifiable and non-modifiable:

  • Nonmodifiable: history of fracture as an adult, family history of fracture, female sex, advanced age, European ancestry, and dementia
  • Potentially modifiable: prolonged intake of the prescription drug prednisone, tobacco smoking, intake of soft drinks (containing phosphoric acid), low body weight <58 kg (127 lb), estrogen deficiency, early menopause (<45 years) or bilateral oophorectomy, prolonged premenstrual amenorrhea (>1 year), low calcium and vitamin D intake, alcoholism, impaired eyesight despite adequate correction, recurrent falls, inadequate physical activity (i.e. too little or also if done in excess), high risk of falls, poor health/frailty.

Diagnosis

Dual energy X-ray absorptiometry (DXA, formerly DEXA) is considered the gold standard for diagnosis of osteoporosis. Diagnosis is made when the bone mineral density is equal to or greater than 2.5 standard deviations below that of a young adult reference population. This is translated as a T-score. The World Health Organization has established diagnostic guidelines as T-score -1.0 or greater is "normal", T-score between -1.0 and -2.5 is "low bone mass" (or "osteopenia") and -2.5 or below as osteoporosis. A low trauma or osteoporotic fracture, defined as one that occurs as a result of a fall from a standing height, is also diagnostic of osteoporosis regardless of the T-score.

In order to differentiate between "primary" (post-menopausal, regardless of age, or senile - related to age) and "secondary" osteoporosis, blood tests and X-rays are usually done to rule out cancer with metastasis to the bone, multiple myeloma, Cushing's disease and other causes mentioned above.

Etiology

Estrogen deficiency following menopause causes a rapid reduction in BMD. This, plus the increased risk of falling associated with aging, leads to fractures of the wrist, spine and hip. Other hormone deficiency states can lead to osteoporosis, such as testosterone deficiency. Glucocorticoid or thyroxine excess states also lead to osteoporosis. Lastly, calcium and/or vitamin D deficiency from malnutrition increases the risk of osteoporosis.

Read more at Wikipedia.org


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Can examination findings predict osteoporosis risk?
From American Family Physician, 10/1/05 by Caroline Wellbery

Osteoporosis causes 1.5 million fractures each year in the United States, and this number is expected to rise as the population ages. Guidelines exist to identify high-risk older women by using bone mineral density (BMD) screening, but identifying osteoporosis risk in younger patients is more complicated. Green and associates conducted a meta-analysis to determine how accurate and precise physical examination findings are in predicting osteoporosis, osteopenia, and spinal fracture risk.

The authors searched MEDLINE to identify studies that compared physical examination findings with bone densitometry or incidences of vertebral fractures. Examination findings included weight, height loss, armspan height, self-reported thoracic kyphosis, wall-occiput distance (i.e., the distance from the back of the head to the wall), rib-pelvis distance, hand skinfold thickness, grip strength, and tooth count.

Fourteen studies were included in the authors' final analysis. Overall, height loss was a useful examination tool, but its efficacy in identifying osteoporosis risk was inconclusive. Armspan declined at about one half the rate of height as patients aged, and the armspan-height difference was a poor predictor of osteoporotic fractures. Low weight was consistently associated with fracture risk. A weight less than 59 kg (130 lb) was a sensitive, but not specific, risk measure, and lower weight predicted an even higher risk. Self-reported humped back was highly specific in predicting hip osteoporosis. Wall-occiput distance greater than 7 cm pointed toward thoracic fracture, according to one study. Low rib-pelvis distance had a positive likelihood ratio for vertebral fracture. Grip strength showed inconsistent associations with fracture risk. Hand skinfold thickness was not predictive of osteoporosis. Finally, tooth count appeared to correlate with BMD, and less than 20 teeth justifies further screening for osteoporosis.

The authors conclude that, although no single examination finding was sufficient to make a diagnosis of osteoporosis, low body weight, wall-occiput distance, low tooth count, self-reported kyphosis, and low rib-pelvis distance effectively predicted higher fracture and osteoporosis risk. The authors suggest that these findings are effective screening tools in patients who do not meet current BMD screening guidelines.

CAROLINE WELLBERY, M.D.

Green AD, et al. Does this woman have osteoporosis? JAMA December 15, 2004;292:2890-900.

COPYRIGHT 2005 American Academy of Family Physicians
COPYRIGHT 2005 Gale Group

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