27. Bones

Question 1

Hormones that affect calcium?

Answer 1

Increase - PTH (phosphate trashing hormone - decreases phosphate), calcitriol (raises it the most)
Decrease - calcitonin (made in parafollicular cells of thyroid)

Question 2

What is primary hyperparathroidism?

Answer 2

Parathyroid adenoma or hyperplasia

Gland produces lots of PTH, causes increase calcium and low phosphate

Question 3

What is secondary hyperparathroidism/osteomalacia?

Answer 3

Vitamin D deficiency.
CKD.
Liver disease.

Causes osteomalacia.

Where there’s a lack of active vit d (calcitriol) so low calcium. Increase phosphate only in CKD though.

Question 4

What is tertiary hyperparathroidism?

Answer 4

Long-term PTH stimulation through secondary.

Causes hyperplasia where you get autonomous secretion of PTH with no negative feedback.

Question 5

Causes of high calcium?

Answer 5

Primary and tertiary hyperparathyroidism
Malignancy e.g. MM
Sarcoidosis
Thiazine diuretics

Question 6

Signs and symptoms of high calcium?

Answer 6

Stones, bones, thrones, abdo moans and psy groans.

Stones, bone pain, polyuria, abdo pain, psych conditions

It can cause pancreatitis too

Question 7

Causes of low calcium?

Answer 7

Secondary hyperparathyroidism (vit d deficiency)
Surgical complications - thyroid surgery
Autoimmune hyperparathyroidism

Question 8

Signs and symptoms of low calcium?

Answer 8

CATs go numb

Trousseau’s sign
Chvostek’s sign

Question 9

What is saponification?

Answer 9

Build up of calcium in pancreatitis where it forms salts. This depletes calcium levels, so patients have low calcium levels.

Question 10

Risk factors and symptoms for primary hyperparathyroidism?

Answer 10

MEN-1 or MEN-2
Hypertension

Signs of hypercalcaemia

On X-RAY -
Subperiosteal bone resorption
Acro-osteolysis
Pepper pot skull

Question 11

Secondary hyperparathyroidism signs and symptoms?

Answer 11

This is a lack of vit d, so causes osteomalacia/rickets

Fractures
Bone pain
Proximal myopathy (cushing's, osteo, thyrotoxicosis can cause)
Fatigue
Hypocalcaemia symptoms

In kids - bowed legs and knock knees

Question 12

Hyperparathyroidsism investigations?

Answer 12

Bloods - U&Es, LFTs (for liver cause of secondary), calcium, phosphate, PTH

Question 13

Management of primary hyperparathyroidism?

Answer 13

Acute hypercalcaemia

• IV fluids
• Bisphosphonates
• Total parathyroidectomy (risk recurrent laryngeal nerve damage)
• Cinacalcet if not suitable for surgery

Question 14

How do we manage secondary hyperparathyroidism?

Answer 14

IV calcium infusion (calcium gluconate)

• Vitamin D (inactive)
• Treat CKD and give active vit d

Question 15

What is paget’s disease and its phases?

Answer 15

A genetic disorder of bone remodelling

1. Lytic phase with hyperactive osteoclasts
2. Mixed phase - compensation with osteoblasts
3. Sclerotic phase - hyperactive osteoblasts cause abnormal bone formation

Onset is insidious
Can affect nerves (cause hearing problems)

Question 16

Investigations for paget’s disease?

Answer 16

Basic bloods.
Calcium, phosphate and PTH will all be normal.
However, ALP will be increased.

Serum CTX and P1NP are bone resorption and formation markers respectively.

X-rays
Bone scan (Tec 99)

Question 17

How do we manage paget’s disease?

Answer 17

Largely supportive

Bisphosphonates (alendronic acid/zoledronic acid) for symptomatic patients

Question 18

What is osteoporosis and causes?

Answer 18

Reduced bone density

Primary - post-menopausal, elderly
Secondary - drugs (steroids, thyroxine), cushing’s disease, hyperPTH, hyperT
GI - coeliac’s, IBD

Question 19

Signs and symptoms of osteoporosis?

Answer 19

Often asymptomatic
Fragility fractures
Back pain

NOF, colles, vertebral most common (there’s a 4th)

Question 20

Investigations for osteoporosis?

Answer 20

Bloods (usually all normal)
X-rays
DEXA scan
- T score - less than -2.5 is Osteoporosis.
between that and -1 is osteopenia
- Z score (same as T but age matched)

FRAX score is 10 year risk of developing fragility fractures.

Question 21

How to treat osteoporosis?

Answer 21

Bisphosphonates

Calcium and vitamin D supplements

Question 22

SLIDE IMAGES!!!!! THE TABLE looks so helpful pls

Answer 22

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