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MSK > Bone Disease > Flashcards

Bone Disease Flashcards

1
Q

What is osteoporosis?

A

Micro deterioration of bone tissue

Low bone mass causing fragile bones

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2
Q

What are the symptoms of osteoporosis

A

No symptoms

Increased fracture risk due to weak thin bones

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3
Q

What are the bone formation cells

A

Osteoblasts

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4
Q

What causes bone resorption

A

Osteoblasts

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5
Q

What stimulates

A 
RANK ligand in normal process 
PTH in pathological process e.g. metastatic / kidney 
Vit D needs to produce calcitriol 
Sun 
Glucocorticoids
Il-1,2, TNF-A
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6
Q

What are osteoblasts formed from

A

Mesenchymal progenitor cells

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7
Q

What are osteoclasts formed from

A

Myeloid progenitor cells

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8
Q

What are the endocrine causes of osteoporosis ?

A 
Thyrotoxicosis 
Cushing's 
Hyperprolactin 
Hyperparathyroid and hypo
Low sex hormones 
GH deficiency
DM
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9
Q

What are the rheumatic causes of osteoporosis?

A

RA
AS
Polymyalgia
IL weaken bones

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10
Q

What are the GI causes of osteoporosis

A 
Anything that causes malabsorption 
Coeliac 
CF 
Pancreatitis 
Ischaemic bowel 
Whipple's 
IBD 
Primary biliary cirrhosis 
Liver Cirrhosis
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11
Q

What are other RF for osteoporosis

A 
Age
Female 
Low BMI 
Alcohol 
Smoking 
Reduced mobility 
Long term steroid 
Other meds - SSRI, PPI, AED, anti-oestrogen, warfarin 
FH
Eating disorder
HIV
Premature menopause 
MM / lymphoma 
CKD 
Osteogenesis imperfecta
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12
Q

What are RF for fracture

A 
Age
Female
Low BMD
Falls 
Low BMI
Osteoporosis
Disorder of bone turnover = Paget's
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13
Q

Who gets DEXA

A 
>10% FRAX RISK 
Low energy fracture
Steroids 
Women >65
Men >75
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14
Q

What does fracture risk assmessment tool (FRAX) looks at

A 
Age
Sex
Weight - low BMI 
Height 
Hx of glucocorticoid use
RA
Alcohol
Previous fracture 
Parental hip fracutre
Smoking
Other causes secondary
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15
Q

Who should you assess for osteoporosis using FRAX

A 
Women >65
Men >75
Younger if 
Previous fracture
Steroid use
Hx falls
FH hip fracture
If have causes of secondary
Low BMI
Smoking
Alcohol
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16
Q

What do you do to assess as a minimum

A 
H+E
FBC, U+E, LFT, TFT, CRP
Albumin
Bone profile - serum Ca, phosphate, ALP, vit D, PTH
- Mg may be needed
Myeloma screen 
DEXA
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17
Q

What are the reasons for above tests

A

Exclude diseases that can mimic e.g. myeloma / osteomalacia
Find cause
Assess risk

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18
Q

How do you treat

A 
Minimise RF
- Activity and exercise
- Healthy weight
- Stop smoking 
- Reduce alcohol 
Falls prevention
Biphosphonates + vitamin D /Ca = 1st line
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19
Q

What are other options

A 
Testosterone if low
HRT
SERM
Denosumab
Teriparatide
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20
Q

What are SE of SERM

A

Worsen menopause
Increased VTE risk
Decreased risk of breast cancer but increased risk of endometrial

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21
Q

What is Denosumab

A

Monoclonal Ab which inhibits RANK and osteoclast
Given SC every 6 months
Use if unable to tolerate biphosphoantes

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22
Q

What is teriparatide

A

Synthetic pTH

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23
Q

When do you give HRT

A

Only if vasomotor Sx as increased risk of CVS and breast cancer

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24
Q

Examples of biphosphonates

A

Alendronate = 1st line but GI upset

Risedronate if can’t tolerate = 2nd line

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25
What do biphosphonates do
Inhibits osteoclasts
26
What are they used in
Prevention and Rx osteoporosis Hypercalcaemia Paget's Pain from bone mets
27
What else do you prescribe supplements in osteoporosis
If Ca intake is inadequate | Always give vit D
28
What are SE of biphosphonates
``` CI if egFR <35 Oesophagitis N+V Oesophageal ulcer Osteonecrosis of jaw - get dental exam Uveitis Fever / myalgia / arthralgia Hypocalcaemia May cause atypical stress fractures by inhibiting turnover so take holiday ```
29
What are you advised to do when taking
Swallow whole with water sitting or standing On empty stomach Take 30 minutes before breakfast Stand or sit upright for at least 30 minutes
30
When should you do after 5 years of Rx with biphosphontes
``` Reasses with FRAX and DEXA Stop and reassess in two years if - If <75 - T score femoral neck >-2.5 - Low risk ``` Continue regardless if - >75 - Hx glucocorticoid - Hip or vertebrae fracture - Fracture on Rx - FRAX high
31
When do steroids become risky for bone health
If >7.5mg for >3 months
32
When do you give prophylaxis bone protection and what do you give
Oral bipshophoante + ensure CA / vit D levels ok If on steroid >3 months If >65 + previous fracture If <65 + DEXA result <1.5
33
What is T score on DEXA
No of SD's below young adult of same sex and BMD
34
What is Z score
No of SD below that of same age, sex and race If normal Z but T score low then osteoporosis normal for age May need not need DEXA if >75 and definite osteoporosis fracture
35
What other investigations could you do for cause
``` PTH - hyperPTH Testosterone / FSH / LH - low? Serum prolactin - high? 24 hour urinary cortisol / Dex suppression for Cushing's Coeliac screen ``` Other causes pathological fracture - X-ray for malignancy - Myeloma screen - Isotope bone scan
36
Why does vit D deficiency cause osteomalacia
Vit D needed to release Ca from bone Decreased plasma Ca PTH increased Causes release of phosphate and Ca from bone
37
What is osteomalacia
Severe vit d or calcium deficiency leading to insufficient mineralisation of bone
38
What causes osteomalacia
``` Malabsorption - IBD Lack of sunlight / dark skin Poor diet Renal failure Drug induced Vit D resistant Liver cirrhosis ```
39
What are symptoms of RIcket's (before growth plate fusion)
``` Lethargy Large forehead Stunted growth Splayed epiphyses Wide joints at elbow and wrist and legs and ankles Bow legs Knock knees Odd curve spine and ribs Features of hypocalcaemia ```
40
What are symptoms of osteomalacia
``` Bone pain Muscle weakness Fractures Increased falls Proximal myopathy ```
41
How do you Dx
``` X-ray Bloods - Low vit D - Low Ca - Low phosphate - Raised ALP - Raised PTH DEXA will show low BMD ```
42
What is seen on X-ray
Lucer zones Osteopenia Stress fracture
43
How do you Rx
Vit D / calcium
44
What is Paget's
Disorder of bone turnover Increased resorption / formation Excessive chaotic deposition
45
What does this lead too
Disorganised bone Bigger and less compact More vascular so pulsating pain Fracture and deformity
46
What are the symptoms
``` >40 and rare unil >60 Isolated elevated ALP Bone pani Deformity Fractures Excessive heat Neuro e.g. hearing loss if in skull ```
47
What can it lead too
``` Osteosarcoma but rare Spinal stenosis Cord compression Cardiac failure Skull thickening Haemorrhage in bone surgery ```
48
What does Paget's affect in order
Spine Skull Pelvis Femur
49
Who is at risk
Age Male FH
50
How do you Dx What is most useful
ALP Ca and phosphate typically normal X-ray shown thickened sclerotic bone with dense and Lucent area BONE SCAN = MOST USEFUL
51
How do you treat
``` IV biphosphonate One off zoledronic acid infusion NSAID for pain Ca + vit D esp when on biphosphoantes Monitor ALP ```
52
When do you treat
Symptomatic
53
What is differential
Malignancy
54
What is osteogenesis imperfect
Genetic connective tissue / type 1 collagen disorder AD Results in bone fragility and fractures 8 types
55
What are symptoms
``` Fragile bones Easily fractured mild trauma Growth deficiency Defective tooth formation (dentigenesis imperfecta) Hearing loss due to otosclerosis Blue sclera Scoliosis Barrel chest Easy bruising Hypermobiltiy ```
56
How do you Dx hypermobility
Beighton score
57
What is shown on X-ay
Translucent bone | Multiple fracture
58
How do you treat
Surgery for fracture IV biphosphonates Education Genetic counselling
59
What is osteopetrosis
AD disorder causing harder more dense bones
60
What does X_ray show
Lack of differentiation between cortex and medulla
61
Lab values osteoporosis
Normal Ca, phosphate, ALP, PTH
62
Lab values osteomalacia
Decreased Ca Decreased phosphate Increased ALP Increased PTH
63
Lab value primary hyperPTH
Increased calcium Decreased phosphate Increased ALP Increased PTH
64
Lab value CKD causing secondary PTH
Decreased calcium Increased phosphate Increased ALP Increased TH
65
Lab value Paget's
Normal calcium Normal phosphate Increased ALP Normal PTH
66
Who gets Vit D supplementation
``` Pregnant Breast feeding Children 6 months - 5 years Formula <500ml Adults >65 No sunlight Osteoporosis ```
67
When should you test via D
Bone disease Osteomalacia Paget's
68
Post menopausal and fracture
Biphosphoantes
69
Lab values of osteogenesis imperecta
Normal calcium Normal phosphate Normal ALP Normal PTH

MSK (21 decks)

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