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Rheumatology > bones + injuries > Flashcards

bones + injuries Flashcards

1
Q

What is osteoporosis

A

reduction in the density of the bones

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2
Q

What is osteopaenia

A

less severe reduction in bone density than osteoporosis

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3
Q

What are the risk factors for osteoporosis

A 
Older age
Female
Reduced mobility and activity
Low BMI (<18.5 kg/m2)
Rheumatoid arthritis
Alcohol and smoking
Long term corticosteroids
Other medications
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4
Q

What medications can icrease risk of osteoporosis

A 
SSRIs
 PPIs
 anti-epileptics 
anti-oestrogens.
Long term corticosteroids
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5
Q

Why are post-menopausal woman at risk of osteoporosis

A
  • 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.
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6
Q

What is the FRAX tool

A
  • 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
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7
Q

What is bone mineral density

A
  • 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
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8
Q

What is a Z score

A

the number of standard deviations the patients bone density falls below the mean for their age

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9
Q

What is a T score

A

he number of standard deviations below the mean for a healthy young adult their bone density is.

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10
Q

What is considered a normal T score

A

> -1

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11
Q

What T score is considered to be osteopaenia

A

-1 - -2.5

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12
Q

What T score is considered to be Osteoporosis

A
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13
Q

Who should have a FRAX assessment

A
  • 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.
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14
Q

What is the result of a FRAX outcome without a mineral bone density

A
  • Low risk – reassure
  • Intermediate risk – offer DEXA scan and recalculate the risk with the results
  • High risk – offer treatment
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15
Q

What lifestyle changes can be done if osteoporotic

A 
Activity and exercise
Maintain a health weight
Adequate calcium intake
Adequate vitamin D
Avoiding falls
Stop smoking
Reduce alcohol consumption
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16
Q

Who should given vitamin D and calcium

A
  • 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.
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17
Q

What do bisphosphonates do?

A

work by interfering with osteoclasts and reducing their activity, preventing the reabsorption of bone

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18
Q

Key side effects of bisphosphonates

A

Reflux and oesophageal erosions
Atypical fractures (e.g. atypical femoral fractures)
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal

19
Q

What advice do you give patients taking bisphosphonates

A

taken on an empty stomach sitting upright for 30 minutes before moving or eating

20
Q

examples of bisphosphonates

A

Alendronate 70mg once weekly (oral)
Risedronate 35 mg once weekly (oral)
Zolendronic acid 5 mg once yearly (intravenous)

21
Q

If bisphosphonates are contraindicated, not tolerated or not effective what other options are there

A
  • Denoxumab: monoclonal antibody
  • Strontium ranelate
  • Raloxifene is used as secondary prevention only
  • Hormone replacement therapy
22
Q

Strontium ranelate can increase the risk of what

A

DVT, PE and myocardial infarction.

23
Q

How often should people have repeat DEXA scans

A
  • Low risk no rx: 5 years

- On bisphosphonates: 3-5 years

24
Q

Who should have a treatment holiday

A
  • 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.
25
Q

What is osteomalacia

A
  • defective bone mineralisation causing “soft” bones

- Results from vitamin D deficiency

26
Q

Possibly presentation of Vitamin d deficiency and osteomalacia

A 
Fatigue
Bone pain
Muscle weakness
Muscle aches
Pathological or abnormal fractures
27
Q

risk factors for vit d deficiency

A
  • darker skin
  • low exposure to sunlight
  • live in colder climates
  • spend the majority of their time indoors.
28
Q

What is considered normal vitamina D levels

A

Serum 25-hydroxyvitamin D

  • <25 nmol/L – vitamin D deficiency
  • 25 – 50 nmol/L – vitamin D insufficiency
  • 75 nmol/L or above is optimal
29
Q

What other investigations could you do when considering a low vitamin D

A
  • 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
30
Q

What is the management of low vitamin D

A
  • Supplementary vitamin D (colecalciferol).
  • Initial a very high dose for 4-7 weeks
  • Maintenance dose of 800 units for life
31
Q

What is Pagets disease of the bone

A
  • 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
32
Q

What is the presentation of a patient with pagets disease

A

Bone pain
Bone deformity
Fractures
Hearing loss can occur if it affects the bones of the ear

33
Q

What may you see on X ray in a patient with Pagets disease

A
  • 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
34
Q

What is osteoporosis circumscripta

A

describes well defined osteolytic lesions that appear less dense compared with normal bone

35
Q

What blood result may you see in a patient with Paget’s disease

A

Raised alkaline phosphatase (and other LFTs are normal)
Normal calcium
Normal phosphate

36
Q

What is the management of Pagets disease

A
  • Bisphosphonates
  • NSAIDs for bone pain
  • Calcium and vitamin D supplementation, particularly whilst on bisphosphonates
37
Q

How do you monitor patients with Paget’s disease

A
  • Monitor ALP, if treatment is under control ALP should be normal
38
Q

What are the complications of Pagets Disease

A 
Osteogenic sarcoma (osteosarcoma)
Spinal stenosis and spinal cord compression
39
Q

What is Osteosarcoma

A
  • 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

40
Q

How does osteosarcoma present

A
  • increased focal bone pain, bone swelling or pathological fractures
  • Usually seen on plain X ray
41
Q

What is spinal stenosis

A
  • 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
42
Q

What is the management of spinal stenosis

A
  • treated with bisphosphonates

- Surgical intervention may be considered.

43
Q

Key features of lateral epicondylitis

A
  • 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
44
Q

What is the management of lateral epicondylitis

A

advice on avoiding muscle overload
simple analgesia
steroid injection
physiotherapy

Rheumatology (5 decks)

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