bones + injuries Flashcards
What is osteoporosis
reduction in the density of the bones
What is osteopaenia
less severe reduction in bone density than osteoporosis
What are the risk factors for osteoporosis
Older age Female Reduced mobility and activity Low BMI (<18.5 kg/m2) Rheumatoid arthritis Alcohol and smoking Long term corticosteroids Other medications
What medications can icrease risk of osteoporosis
SSRIs PPIs anti-epileptics anti-oestrogens. Long term corticosteroids
Why are post-menopausal woman at risk of osteoporosis
- oestrogen is a protective factors
- Unless they are on HRT postmenopausal women have less oestrogen
- They also tend to be are older and often have other risk factors for osteoporosis.
What is the FRAX tool
- gives a prediction of the risk of a fragility fracture over the next 10 year
- Involves looking at their BMI, smoking & alcohol history, FH and co-morbidities
- % 10 year probability of a:
Major osteoporotic fracture
Hip fracture
What is bone mineral density
- measured using a DEXA scan
- measured at any location on the skeleton, but the reading at the hip is best for FRAX assessment
- Bone density can be represented as a Z score or T score
What is a Z score
the number of standard deviations the patients bone density falls below the mean for their age
What is a T score
he number of standard deviations below the mean for a healthy young adult their bone density is.
What is considered a normal T score
> -1
What T score is considered to be osteopaenia
-1 - -2.5
What T score is considered to be Osteoporosis
Who should have a FRAX assessment
- Women aged > 65
- Men > 75
- Younger patients with risk factors such as a previous fragility fracture, history of falls, low BMI, long term steroids, endocrine disorders and rheumatoid arthritis.
What is the result of a FRAX outcome without a mineral bone density
- Low risk – reassure
- Intermediate risk – offer DEXA scan and recalculate the risk with the results
- High risk – offer treatment
What lifestyle changes can be done if osteoporotic
Activity and exercise Maintain a health weight Adequate calcium intake Adequate vitamin D Avoiding falls Stop smoking Reduce alcohol consumption
Who should given vitamin D and calcium
- patients at risk of fragility fractures with an inadequate intake of calcium
- Patients with an adequate calcium intake but lacking sun exposure should have vitamin D supplementation.
What do bisphosphonates do?
work by interfering with osteoclasts and reducing their activity, preventing the reabsorption of bone
Key side effects of bisphosphonates
Reflux and oesophageal erosions
Atypical fractures (e.g. atypical femoral fractures)
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal
What advice do you give patients taking bisphosphonates
taken on an empty stomach sitting upright for 30 minutes before moving or eating
examples of bisphosphonates
Alendronate 70mg once weekly (oral)
Risedronate 35 mg once weekly (oral)
Zolendronic acid 5 mg once yearly (intravenous)
If bisphosphonates are contraindicated, not tolerated or not effective what other options are there
- Denoxumab: monoclonal antibody
- Strontium ranelate
- Raloxifene is used as secondary prevention only
- Hormone replacement therapy
Strontium ranelate can increase the risk of what
DVT, PE and myocardial infarction.
How often should people have repeat DEXA scans
- Low risk no rx: 5 years
- On bisphosphonates: 3-5 years
Who should have a treatment holiday
- 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.
What is osteomalacia
- defective bone mineralisation causing “soft” bones
- Results from vitamin D deficiency
Possibly presentation of Vitamin d deficiency and osteomalacia
Fatigue Bone pain Muscle weakness Muscle aches Pathological or abnormal fractures
risk factors for vit d deficiency
- darker skin
- low exposure to sunlight
- live in colder climates
- spend the majority of their time indoors.
What is considered normal vitamina D levels
Serum 25-hydroxyvitamin D
- <25 nmol/L – vitamin D deficiency
- 25 – 50 nmol/L – vitamin D insufficiency
- 75 nmol/L or above is optimal
What other investigations could you do when considering a low vitamin D
- Serum calcium is low
- Serum phosphate is low
- Serum alkaline phosphatase may be high
- Parathyroid hormone may be high (secondary hyperparathyroidism)
- Xrays may show osteopenia (more radiolucent bones)
- DEXA scan shows low bone mineral density
What is the management of low vitamin D
- Supplementary vitamin D (colecalciferol).
- Initial a very high dose for 4-7 weeks
- Maintenance dose of 800 units for life
What is Pagets disease of the bone
- excessive bone turnover due to excessive activity of both osteoblasts and osteoclasts
- excessive turnover is not coordinated, leading to patchy areas of high density (sclerosis) and low density (lysis).
- Increase risk of pathological fracture
- Usually affects axial skeleton
What is the presentation of a patient with pagets disease
Bone pain
Bone deformity
Fractures
Hearing loss can occur if it affects the bones of the ear
What may you see on X ray in a patient with Pagets disease
- Bone enlargement and deformity
- “Osteoporosis circumscripta”
“Pepper pot skull”
“V-shaped defects” in the long bones are V shaped osteolytic bone lesions within the healthy bone
What is osteoporosis circumscripta
describes well defined osteolytic lesions that appear less dense compared with normal bone
What blood result may you see in a patient with Paget’s disease
Raised alkaline phosphatase (and other LFTs are normal)
Normal calcium
Normal phosphate
What is the management of Pagets disease
- Bisphosphonates
- NSAIDs for bone pain
- Calcium and vitamin D supplementation, particularly whilst on bisphosphonates
How do you monitor patients with Paget’s disease
- Monitor ALP, if treatment is under control ALP should be normal
What are the complications of Pagets Disease
Osteogenic sarcoma (osteosarcoma) Spinal stenosis and spinal cord compression
What is Osteosarcoma
- type of bone cancer with a very poor prognosis
- The risk is increased in Paget’s disease and patients need to be followed up to detect it early
How does osteosarcoma present
- increased focal bone pain, bone swelling or pathological fractures
- Usually seen on plain X ray
What is spinal stenosis
- deformity in the spine leads to spinal canal narrowing
- If this presses on the spinal nerves it causes neurological signs and symptoms.
- diagnosed with an MRI scan
What is the management of spinal stenosis
- treated with bisphosphonates
- Surgical intervention may be considered.
Key features of lateral epicondylitis
- pain and tenderness lateral epicondyle
- worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended
- 6 months and 2 years
- acute pain for 6-12 weeks
What is the management of lateral epicondylitis
advice on avoiding muscle overload
simple analgesia
steroid injection
physiotherapy
