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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
Q

What do biphosphonates do

A

Inhibits osteoclasts

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26
Q

What are they used in

A

Prevention and Rx osteoporosis
Hypercalcaemia
Paget’s
Pain from bone mets

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27
Q

What else do you prescribe supplements in osteoporosis

A

If Ca intake is inadequate

Always give vit D

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28
Q

What are SE of biphosphonates

A 
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
Q

What are you advised to do when taking

A

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
Q

When should you do after 5 years of Rx with biphosphontes

A 
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
Q

When do steroids become risky for bone health

A

If >7.5mg for >3 months

32
Q

When do you give prophylaxis bone protection and what do you give

A

Oral bipshophoante + ensure CA / vit D levels ok
If on steroid >3 months
If >65 + previous fracture
If <65 + DEXA result <1.5

33
Q

What is T score on DEXA

A

No of SD’s below young adult of same sex and BMD

34
Q

What is Z score

A

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
Q

What other investigations could you do for cause

A 
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
Q

Why does vit D deficiency cause osteomalacia

A

Vit D needed to release Ca from bone
Decreased plasma Ca
PTH increased
Causes release of phosphate and Ca from bone

37
Q

What is osteomalacia

A

Severe vit d or calcium deficiency leading to insufficient mineralisation of bone

38
Q

What causes osteomalacia

A 
Malabsorption - IBD 
Lack of sunlight / dark skin 
Poor diet
Renal failure
Drug induced
Vit D resistant 
Liver cirrhosis
39
Q

What are symptoms of RIcket’s (before growth plate fusion)

A 
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
Q

What are symptoms of osteomalacia

A 
Bone pain
Muscle weakness
Fractures
Increased falls
Proximal myopathy
41
Q

How do you Dx

A 
X-ray 
Bloods
- Low vit D
- Low Ca 
- Low phosphate 
- Raised ALP
- Raised PTH
DEXA will show low BMD
42
Q

What is seen on X-ray

A

Lucer zones
Osteopenia
Stress fracture

43
Q

How do you Rx

A

Vit D / calcium

44
Q

What is Paget’s

A

Disorder of bone turnover
Increased resorption / formation
Excessive chaotic deposition

45
Q

What does this lead too

A

Disorganised bone
Bigger and less compact
More vascular so pulsating pain
Fracture and deformity

46
Q

What are the symptoms

A 
>40 and rare unil >60
Isolated elevated ALP
Bone pani
Deformity
Fractures 
Excessive heat
Neuro e.g. hearing loss if in skull
47
Q

What can it lead too

A 
Osteosarcoma but rare
Spinal stenosis  
Cord compression 
Cardiac failure
Skull thickening
Haemorrhage in bone surgery
48
Q

What does Paget’s affect in order

A

Spine
Skull
Pelvis
Femur

49
Q

Who is at risk

A

Age
Male
FH

50
Q

How do you Dx

What is most useful

A

ALP
Ca and phosphate typically normal
X-ray shown thickened sclerotic bone with dense and Lucent area
BONE SCAN = MOST USEFUL

51
Q

How do you treat

A 
IV biphosphonate
One off zoledronic acid infusion
NSAID for pain 
Ca + vit D esp when on biphosphoantes 
Monitor ALP
52
Q

When do you treat

A

Symptomatic

53
Q

What is differential

A

Malignancy

54
Q

What is osteogenesis imperfect

A

Genetic connective tissue / type 1 collagen disorder
AD
Results in bone fragility and fractures
8 types

55
Q

What are symptoms

A 
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
Q

How do you Dx hypermobility

A

Beighton score

57
Q

What is shown on X-ay

A

Translucent bone

Multiple fracture

58
Q

How do you treat

A

Surgery for fracture
IV biphosphonates
Education
Genetic counselling

59
Q

What is osteopetrosis

A

AD disorder causing harder more dense bones

60
Q

What does X_ray show

A

Lack of differentiation between cortex and medulla

61
Q

Lab values osteoporosis

A

Normal Ca, phosphate, ALP, PTH

62
Q

Lab values osteomalacia

A

Decreased Ca
Decreased phosphate
Increased ALP
Increased PTH

63
Q

Lab value primary hyperPTH

A

Increased calcium
Decreased phosphate
Increased ALP
Increased PTH

64
Q

Lab value CKD causing secondary PTH

A

Decreased calcium
Increased phosphate
Increased ALP
Increased TH

65
Q

Lab value Paget’s

A

Normal calcium
Normal phosphate
Increased ALP
Normal PTH

66
Q

Who gets Vit D supplementation

A 
Pregnant
Breast feeding
Children 6 months - 5 years
Formula <500ml
Adults >65
No sunlight
Osteoporosis
67
Q

When should you test via D

A

Bone disease
Osteomalacia
Paget’s

68
Q

Post menopausal and fracture

A

Biphosphoantes

69
Q

Lab values of osteogenesis imperecta

A

Normal calcium
Normal phosphate
Normal ALP
Normal PTH

MSK (21 decks)

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