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Ageing and Health > Bone Disease > Flashcards

Bone Disease Flashcards

1
Q

List extrinsic risk factors for falls (STUMBLING mnemonic)

A
  • Stuff (clothes, shoes, furniture)
  • Trailing wires
  • Uneven, wet, polished floors
  • Mobility problems – rolator
  • Bad lighting
  • Loose rugs
  • Ill fitting footwear
  • Nocturnal low temp
  • Glare and shadow
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2
Q

List intrinsic risk factors for falls

A
  • Postural hypotension
  • Cardiac – MI / arrhythmia
  • Valvular heart disease
  • Vasovagal
  • Dizziness
  • TIAs / Strokes
  • Epilepsy
  • Cervical spondylosis
  • General debility
  • Visual impairment
  • Diffuse brain disease / dementia
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3
Q

What is osteoporosis?

A

Reduction in the amount of bone AND loss of micro-architecture leading to weakened bone and pathological fracture

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4
Q

What are the causes of osteoporosis?

A

Primary: post-menopausal

Secondary: racism mnemonic

R = rheumatoid arthritis
A = alcohol excess
C = corticosteroids (most common)
I = immobility
S = smoking
M = multiple myeloma
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5
Q

What are the risk factors of osteoporosis?

A
  • Female
  • Caucasian/Asian
  • Early menopause
  • Sedentary lifestyle
  • Slim body build
  • Nulliparity
  • Amenorrhoea
  • Positive family history
  • Smoking
  • Alcohol intake
  • Steroids
  • Previous fractures
  • Low calcium intake
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6
Q

Outline the significance of gender differences in bone mass/osteoporosis?

A
  • Males have greater peak bone mass than females
  • Without help of HRT, females fall into the notional fracture threshold at a younger age
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7
Q

What is the first step in assessing someone’s risk of osteoporosis?

A
  • FRAX tool
  • The FRAX tool gives a prediction of the risk of a fragility fracture over the next 10 years.
  • age, BMI, co-morbidities, smoking, alcohol and family history. You can enter a result for bone mineral density (from a DEXA scan) for a more accurate result but it can also be performed without the bone mineral density.
  • It gives results as a percentage 10-year probability of a major osteoporotic fracture or hip fracture
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8
Q

Outline the DEXA scan and bone mineral density

A
  • DEXA scan measures BMD
  • X-rays indicate how dense the bone is
  • Reading of hip is key for osteoporosis management
  • Bone density is represented as a Z-score or a T-score
  • Z scores represent the number of SDs the patient’s bone density falls below the mean for their age
  • T scores represent the number of standard deviations below the mean for a healthy young adult their bone density is.
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9
Q

Outline the WHO classification for osteoporosis

A

> -1 = Normal

-1 to -2.5 = Osteopenia

< -2.5 = Osteoporosis

< -2.5 plus a fracture = Severe Osteoporosis

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10
Q

Outline the NOGG guidelines

A

The NOGG Guidelines from 2017 suggest the next step in management based on the probability of a major osteoporotic fracture from the FRAX score:

FRAX outcome without a BMD result will suggest one of three outcomes:

  • Low risk – reassure
  • Intermediate risk – offer DEXA scan and recalculate the risk with the results
  • High risk – offer treatment

FRAX outcome with a BMD result will suggest one of two outcomes:

  • Treat
  • Lifestyle advice and reassure
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11
Q

How is osteoporosis managed?

A
  1. First line = bisphosphonates
  • e.g. Alendronate 70mg once weekly (oral)
  • Risedronate 35 mg once weekly (oral)
  • Zoledronic acid 5 mg once yearly (intravenous)

if contraindicated:

  • Denosumab
  • Strontium ranelate (inc. risk of DVT, PE and myocardial infarction)
  • Raloxifene is used as secondary prevention only.
  • HRT
    2. Vitamin D and calcium e.g. calcichew-D3
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12
Q

Important slide: what are the side-effects of bisphosphonates?

A
  • Reflux and oesophageal erosions. Oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this.
  • Atypical fractures (e.g. atypical femoral fractures)
  • Osteonecrosis of the jaw
  • Osteonecrosis of the external auditory canal
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13
Q
A
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14
Q

Discuss the importance of follow-up management of osteoporosis

A
  • Low-risk patients not being put on treatment should be given lifestyle advice and followed up within 5 years for a repeat assessment.
  • Patients on bisphosphonates should have a repeat FRAX and DEXA scan after 3-5 years and a treatment holiday should be considered if their BMD has improved and they have not suffered any fragility fractures. This involves a break from treatment of 18 months to 3 years before repeating the assessment.
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15
Q

What is osteomalacia?

A
  • A disease characterised by reduced mineralisation of bone
  • Low serum calcium AND phosphate
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16
Q

What is the pathophysiology behind osteomalacia?

A

Vitamin D is a hormone created from cholesterol by the skin in response to UV radiation. Reduced sun exposure without vitamin D supplementation leads to deficiency. Patients with malabsorption disorders (such as inflammatory bowel disease) are more likely to have vitamin D deficiency. The kidneys are essential in metabolising vitamin D to its active form, therefore vitamin D deficiency is common in chronic kidney disease.

Vitamin D is essential in calcium and phosphate absorption from the intestines and kidneys. Vitamin D is also responsible for regulating bone turnover and promoting bone reabsorption to boost the serum calcium level.

Inadequate vitamin D leads to a lack of calcium and phosphate in the blood. Since calcium and phosphate are required for the construction of bone, low levels result in defective bone mineralisation. Low calcium causes a secondary hyperparathyroidism as the parathyroid gland tries to raise the calcium level by secreting parathyroid hormone. Parathyroid hormone stimulates increased reabsorption from the bones. This causes further problems with bone mineralisation.

17
Q

What are the causes of osteomalacia?

A
  • Deficient diet
  • Lack of sun exposure
  • Malabsorption
  • Chronic liver disease
  • Phenytoin therapy
  • Chronic renal disease
  • Hypophosphataemia
18
Q

What are some clinical features of osteomalacia?

A
  • Abnormal blood chemistry
  • Osteopenia on x-ray
  • Pathological fractures
  • Bone pain
  • Proximal myopathy
19
Q

What is Paget’s disease?

A
  • Disease of the bone characterised by increased rate of remodelling - bone resorption and formation
  • Very rare < 40 years old
  • Affects long bones, vertebrae, pelvis and skull
  • Idiopathic but evidence of “slow virus” pathology
20
Q

How does Paget’s disease present?

A
  • Most patients asymptomatic
  • Pathological fracture
  • Bone pain
  • Skeletal deformity - bowing of limbs, enlarged skull
  • Hearing loss if affecting the bones of the ear
21
Q

What are some X-ray findings in Paget’s disease of the bone?

A
  • Bone enlargement and deformity
  • “Osteoporosis circumscripta” describes well defined osteolytic lesions that appear less dense compared with normal bone
  • “Cotton wool appearance” of the skull describes poorly defined patchy areas of increased density (sclerosis) and decreased density (lysis)
  • “V-shaped defects” in the long bones are V shaped osteolytic bone lesions within the healthy bone
22
Q

What are the complications of Paget’s disease?

A
  • Pathological fracture
  • Secondary osteoarthritis
  • Nerve compression - cranial, spinal e.g spinal stenosis and spinal cord compression
  • Development of sarcoma
  • High output cardiac failure
23
Q

Outline the biochemical profile (Ca2+/PO43-/ALP) of the different bone diseases

A

Ageing and Health (11 decks)

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