Breaking is bad Flashcards
What is Osteoporosis?
Osteoporosis is a complex skeletal disease characterised by low bone density and micro-architectural defects in bone tissue, resulting in increased bone fragility and susceptibility to fracture.
What is bone density determined by?
Bone mineral density Size/shape of the bone Bone turnover Micro-architecture Bone mineralisation
What are the risk factors for fractures?
Prior fragility fracture
Female sex (they have lower peak bone mass + have greater declines in bone mass over time
White ancestry
Older age (over 50 for women, over 65 for men).
Low BMI (loss of bone mass is accelerated in those with a lower BMI)
Fam hx of maternal hip fracture
Loss of height (may indicate vertebral fracture)
Post-menopause (oestrogen decline - decreases in bone mineral density).
Prolonged immobilisation (bone mineral density declines).
Vitamin D deficiency (associated with increased PTH production -> increased bone resorption).
Smoking + excessive alcohol intake (bone mass declines more rapidly + increases risk of osteoporosis).
Glucocorticoid excess (50% of people with Cushing’s syndrome experience fractures (esp vertebral)).
What is a DXA scan?
Dual-energy x-ray absorptiometry (DXA). DXA scans measure bone density. The result is given in a T-score which is determined by measuring bone density at the hip. This means they are best at predicting hip fractures. A T-score of < or equal to 2.5 is indicative of osteoporosis. A T-score of < or equal to 2.5 with fragility fractures = indicative of severe or established osteoporosis.
What are the diagnostic tests for osteoporosis?
Dual-energy x-ray absorptiometry
Quantitative ultrasound of the heel
X-rays (heel, wrist, spine, hip)
How would you manage a female patient with high risk of osteoporotic fracture?
Give them bisphosphonate (alendronate) and consider prescribing calcium and vitamin D supplementation too.
If bisphosphonates are contraindicated/not tolerated, then - teriparatide and calcium and vitamin D supplementation.
How would you manage a male patient with osteoporosis and low testerone?
Testosterone added to bisphosphonate (testosterone buccal) + calcium and vitamin D supplementation.
Who should be risk assessed for fragility fractures?
All women aged 65+ and all men aged 75+.
In women aged below 65 and men aged below 75 if they have the relevant risk factors.
What tools can be used to assess risk of fracture?
you can use FRAX (fracture risk assessment tool) with or without BMD value (bone mineral density value) or QFracture to estimate 10-year predicted absolute fracture risk. FRAX - age range = 40-90, with or without BMD values. QFracture - age range = 30-84, BMD values can’t be factored in.
What is a fracture?
A fracture is a soft tissue with a loss of continuity in the bone and there can be different types of fractures depending on the mechanism of action and the place the break is.
What are the different types of fracture?
Stable fracture - the broken ends of the bone line up and are barely out of place.
Open compound fracture - skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound.
Transverse fractures - a horizontal fracture line, an oblique fracture which a fracture in an angled pattern or a comminuted fracture which is where the bone shatters into 3 or more pieces.
What is a hip fracture?
Considered to be any fracture of the femur distal to the femoral head and proximal to a level a few centimetres below the lesser trochanter.
Neck of femur fractures are common injuries sustained by many older patients, who are more likely to have unsteadiness gait as well as reduced bone mineral density.
What causes hip fractures?
Hip fractures are mainly caused by falls from a standing height accounting for a significant majority of hip fractures in older people. This is associated with osteopenia or osteoporotic condition of bone.
In younger people, the primary aetiology is high energy trauma including motor vehicle accidents and falls from a height.
What is the mechanism behind hip fractures in elderly people?
With the elderly patients, the injury has multiple different mechanisms, varying from patients falling directly onto their hips to a twisting mechanism in which the patient’s foot is planted on the floor and the body rotates causing the hip to break.
What is the mechanism behind hip fractures in young people?
In younger patient the fracture is predominantly axial loading during high force trauma, with an abducted hip during injury causing a neck of femur fracture and an adducted hip causing a hip fracture dislocation.
What are the risk factors for hip fractures?
Falls Older age Osteoporosis/osteopenia Malignancy Female High energy trauma Medications Alcohol consumption
How might hip fractures present?
Global pains around the groin and the region on the greater trochanter, with this potentially radiating distally down the femur or up to the pelvis.
Pain is often increased with internal or external rotation of the leg or flexion of the hip.
Weight bearing is either impossible or causes pain in the groin, hip or femur.
How would you investigate hip fractures?
Plain X-rays
Full-length radiograph of the femur to identify bone metastasis
Bloods
MRI or CT scan
What aspects seen on X-ray would suggest a hip fracture?
Shenton’s line disruption: loss of contour between normally continuous line from medial edge of femoral neck and inferior edge of the superior pubic ramus
Lesser trochanter is more prominent due to external rotation of femur
Femur often positioned in flexion and external rotation
Asymmetry of lateral femoral neck/head
Sclerosis in fracture plane
Smudgy sclerosis from impaction
Bone trabeculae angulated
What is a intracapsular fracture?
Intracapsular fractures: The retinacular vessels that pass up the femoral capsule may be damaged, especially if the fracture is displaced, resulting in poor blood supply to the femoral head often leading to avascular necrosis.
What is an extracapsular fracture?
This includes intertrochanteric or subtrochanteric, which typically heal well.
What is the differential diagnosis for a hip fracture?
Acetabular fracture Pubic rami fracture Femoral shaft or subtrochanteric femur fracture Femoral head fracture Septic hip
What is the management for a hip fracture?
Pain relief
Non operative management
Internal fixation
Prosthetic replacement
What are the possible complications from a hip fracture?
Thromboembolic complications
Avascular necrosis
Non union/failure to fixation
What are ankle fractures?
Fractures types in which one or more of either the medial, lateral or posterior malleolus is broken.
Typically in young men and older females.
What causes ankle fractures?
Most commonly caused by a low energy fall, but other causes include inversion injury to the ankle, sporting injury, fall down the stairs, fall from a height and motor vehicle accident.
What are the risk factors for ankle fractures?
Osteoporosis and multiple falls
How might an ankle fracture present?
Swelling that is over the medial or lateral malleolus.
History of slip, fall or other trauma leading to inability to weight bear.
Pain is over the medial or lateral malleolus with associated with bruising.
May have heard a ‘pop’ on fall.
How would you investigate an ankle fracture?
X-ray
Use of Ottwa rules:
Bone tenderness at the posterior edge or tip of the lateral malleolus OR
Bone tenderness at the posterior edge or tip of the medial malleolus OR
Unable to weight bear or walk a few steps
What are the differential diagnosis for an ankle fracture?
Lateral ankle ligament tear
Achilles tendon rupture
How would you manage an ankle fracture?
Open fracture would require emergency surgery with consideration of contacting a vascular team if there appeared to be vascular compromise.
Management options depend of fracture and options can include closed reduction with a split or open reduction and fixation with or without the use of short leg casts.
What are the complications of an ankle fracture?
Fracture non-union- Serious complication that can occur when the fracture moves too much, has a poor blood supply or gets infected – it means the normal process of bone healing is interrupted.
Hardware Irritation
Infection
What is a wrist fracture?
Wrist fractures include fractures that affect the distal end of the radius, ulna and carpus. Fractures of the distal radius are the most common injury and are usually located within the distal inch.
What causes a wrist fracture?
Falls on the outstretched hand are the most common cause of fracture.
Elderly - fall from a standing height
Young - sporting activities, high speed motor vehicle accident
What are the risk factors for wrist fractures?
Trauma and osteoporosis
How would you investigate a wrist fracture?
Plain X rays
MRI or CT pelvis
Consider DXA
Compartment syndrome investigations
What is a Colles’ fracture?
Colles’ fracture classically comprises of a transverse fracture of the distal radius with dorsal displacement and shortening of the wrist. Also possible to get ulnar styloid fracture or fractures of the scaphoid bone in the palm of the hand.
How would you manage a wrist fracture?
Immobilisation of wrist, typically with long arm thumb or a forearm based thumb spica cast or split.
Reduction of displaced fractures.
Open fractures should include debridement and stabilisation is needed followed by antibiotic therapy and tetanus prophylaxis.
Sometimes surgical reduction is required.
Rehab for improvement of arm movement.
What are a possible complications for wrist fractures?
Malunion Joint stiffness Complex regional pain syndrome Continued morbidity from osteoporosis Ulnar styloid non union and ulnar sided wrist pain Distal radius non union Carpal tunnel syndrome Rupture of the extensor pollicis longus Rupture of the flexor pollicis longus
What is a pulled elbow?
A subluxation of the radial head into the annular ligament, which usually spontaneously or easily reduces and rarely demonstrates abnormal radiographic features. It should be distinguished from dislocation of the radial head.
Who usually experiences a pulled elbow?
Usually encounter in young children, who present holding the elbow flexed and the forearm in the prone position, unwilling to supinate it.
How would you manage a pulled elbow?
Management involves supination with the elbow flexed which almost always results in reduction and in infant almost immediate cessation of the symptoms.
What is a Boxers fracture?
Boxers fractures are minimally comminuted, transverse fractures of the 5th metacarpal and are the most common type of metacarpal fracture.
Who usually experiences a Boxers fracture?
They typically occur occur when punching and are a common sight in all A&E on Friday. They are impaction injuries due to a direct blow to a solid surface.
What is a Boxer’s knuckle?
A tendinous and ligamentous disruption of the metacarpal phalangeal joint.
How would you manage a Boxer’s fracture?
Closed reduction can be achieved by stabilising the proximal part of the metacarpal dorsally and applying pressure to the head of the metacarpal from the palmar aspect while flexing the proximal phalanx.
A short arm gutter split is applied, followed by buddy strapping.
Who would come in with a proximal humeral fracture?
Clinically they present following a relatively innocuous fall in elderly patients but with younger patients present following high trauma incidents or perhaps during seizures, electrical shock or following direct trauma.
What causes a proximal humeral fracture?
As they are usually due to an outstretched hand, the indirect forces transmit through the proximal humerus and shoulders are the cause of most fractures. These forces may be compressive, tension, torsion or bending.
How would you investigate a proximal humeral fracture?
Investigations involve plain x ray and occasionally CT if an adequate view can’t be identified.
What’s the treatment for a proximal humeral fracture?
Closed undisplaced fractures are usually treated conservatively, whereas operative open reduction and integral fixation is reserved for displaced fractures. Hemi arthroplasty can take place where there are 3 or 4 parts to the fracture and risk of malunion and avascular necrosis.
What causes humeral shaft fractures?
Mostly are as a result of a blow to the arm but also be due to indirect trauma from a fall or a twisting action resulting spiral or oblique fractures.
How would you investigate a humeral shaft fracture?
Investigations tend to be using plain x ray, and although transverse fractures are usually trivially easy to identify, oblique or spiral fractures can be difficult, so an AP and lateral view is required.
How would you treat a humeral shaft fracture?
Usually treated with a supportive/hanging cast followed by a supportive split.
What nerve damage can occur with a humeral shaft fracture?
Most common association injury with damage to the radial nerve, on account of very close relationship to the posterior aspect of the bone, running in the spiral groove between the lateral and medial heads of the triceps muscle.
What is vitamin D?
Vitamin D is a steroid hormone and made from cholesterol and it’s fat soluble. It is created from cholesterol by the skin in response to UV radiation.
What are the two inactive molecules come from vitamin D?
Either vitamin D2, or ergocalciferol, which comes from plant sources in our diet. Vitamin D3, or cholecalciferol, which can either come from animal products in our diet but can also be made in skin cells that are exposed to sunlight.
How does vitamin D reach the blood?
Vitamin D2 and D3 are absorbed into the intestinal cells along with bile salts called enterocytes.
They are then incorporated into lipoproteins called chylomicrons which get into the lymph and eventually enter the blood.
Vitamin D-binding proteins take them to the liver.
In liver vitamin D2 becomes ergocalciferol (and vitamin D3 becomes calcifediol.
In kidneys, they are hydroxylated by dihydroxyvitamin D, creating the physiologically active form.
When does vitamin D deficiency occur?
A standard diet contains inadequate levels of vitamin D to compensate for a lack of sun exposure.
Reduced sun exposure without vitamin D supplementation leads to vitamin D deficiency.
Patients with malabsorption disorders (such as inflammatory bowel disease) or chronic kidney disease are more likely to have vitamin D deficiency.
What is the role of Vitamin D in the body?
Calcium and phosphate absorption from the intestines and kidneys
Regulating bone turnover and promoting bone reabsorption
Inadequate Vit D means inadequate calcium and phosphate - required for the construction of bone
Inadequate calcium leads to secondary hyperparathyroidism
What are the risk factors of vitamin D deficiency?
Having dark skin. Being elderly. Being overweight or obese. Not eating much fish or dairy. Living far from the equator where there is little sun year-round. Always using sunscreen when going out. Staying indoors.
What are the signs and symptoms of vitamin D deficiency?
Signs: Mood changes, bone loss, muscles cramps/weakness, fatigue, bone and joint pain
Symptoms: Chronic pain, infection, muscle weakness, depression, constant fatigue, respiratory issues, periodontal disease
What diagnosis tools would you use to look for vitamin D deficiency?
Blood test
25-hydroxyvitamin D, known as 25(OH)D for short
X-ray to look for rickets
Serum calcium and Serum phosphate (low)
Serum alkaline phosphatase and Parathyroid hormone (high)
Look for other pathology - FBC, ferritin, ESR, CRP, kidney and liver function tests, thyroid function tests, anti-TTG antibodies, autoimmune and rheumatoid tests
What is the treatment for vitamin D deficiency?
Fixed loading doses of vitamin D in daily or weekly doses, followed by lifelong maintenance treatment.
Safe sun exposure
Dietary sources include cod liver oil, oily fish, egg yolk, meat, offal, milk, mushrooms, and fortified foods.
Dietary intake of calcium should be maintained too.
Who should be treated or vitamin D deficiency?
Treat for vitamin D deficiency if serum 25-hydroxyvitamin D (25[OH]D) levels are less than 25 nmol/L OR if they are between 25-50nmol/L and: - osteoporosis, high fracture risk - symptoms - antiresorptive drug for bone disease - reduced sunlight exposure - high parathyroid hormone - antiepileptic drug or an oral corticosteroid - malabsorption disorder or CKD
How can vitamin D deficiency lead to Rickets?
Severe lack of vitamin D causes rickets, which shows up in children as incorrect growth patterns, weakness in muscles, pain in bones and deformities in joints. This is very rare.
What are the bone deformities caused by Rickets?
Bowing of the legs, where the legs curve outwards
Knock knees, where the legs curve inwards
Rachitic rosary, where the ends of the ribs expand at the costochondral junctions, causing lumps along the chest
Craniotabes, which is a soft skull, with delayed closure of the sutures and frontal bossing
Delayed teeth with under-development of the enamel
How would you treat Rickets?
Vitamin D and calcium supplementation is used to treat rickets.
What is hypercalcemia?
Hypercalcemia is an elevated calcium (Ca2+) level in the blood, which is often indicative of other diseases.
How do patients with hypercalcemia present?
Patients commonly present with renal or biliary stones, bone pain, abdominal discomfort, nausea, vomiting, excessive urination, and mental impairment
What leads to high calcium in the body?
Hypercalcemia can result from excessive skeletal calcium release, increased intestinal calcium absorption, or decreased renal calcium excretion.
What is the major cause of hypercalcemia?
Primary hyperparathyroidism is one of the leading causes of hypercalcaemia, and one of the most common endocrine disorders.
How is the calcium level maintained within a narrow range?
When the body’s levels of extracellular calcium change, it’s detected by a surface receptor in parathyroid cells called the calcium-sensing receptor. This affects the amount of parathyroid hormone that gets released by the parathyroid gland. The parathyroid hormone gets the bones to release calcium and gets the kidneys to reabsorb more calcium so it’s not lost in the urine and synthesize calcitriol also known as active vitamin D. Active vitamin D then goes on to increase calcium absorption in the gastrointestinal tract. All together, these effects help to keep the extracellular levels of calcium within a very narrow range, between 8.5 to 10 mg/dl.
What are the symptoms of hypercalcemia?
Bones, stones, groans and psychic moans Abdominal pain Polyuria Polydipsia Anorexia Weight loss Weakness ECG changes seen in hypercalcaemia can include short QT, bradycardia, bundle branch block or AV block
What causes hypercalcemia?
Calcium supplementation, hyperparathyroidism, immobilization,
Multiple myeloma, milk alkali syndrome, medication like lithium
Parathyroid hyperplasia, alcohol, excess vitamin A & D
What’s the treatment for hypercalcemia?
For symptomatic parathyroid adenoma is surgical removal
In parathyroid hyperplasia all four glands are removed
What is the emergency treatment for hypercalcemia?
Rehydrate with IV fuid
Bisphosphonate infusion (pamidronate)
Measure serum urea, and electrolytes daily
Prednisolone (30-60mg)
Prevent recurrence by treating underlying cause
