Investigation and Management of Bone Disease

Question 1

What is the definition of osteoporosis? (3 marks)

Answer 1

Low bone mass

Micro-architectural deterioration

Enhanced bone fragility and risk of fracture

Question 2

What is a fragility fracture?

Answer 2

Fractures caused by low energy trauma

Question 3

Which medication group is linked with osteoporosis?

Answer 3

Steroids *Also the pill

Question 4

What investigation is used for osteoporosis diagnosis?

Answer 4

Dual Energy X-ray Absorpitometry (DEXA scan)

T score = gender matched comparison

Z score = gender and age matched comparison

Question 5

What is the DEXA threshold for osteoporosis?

Answer 5

T-score

• 0 to -1 = -1 normal
• -1 to -2.5 = -osteopenia
• -2.5 below = osteoporosis
• -2.5 below + fracture = severe osteoporosis

Question 6

What tools can be used to assess fracture risk?

Answer 6

Fracture Risk Assessment Tool (FRAX)

Question 7

What is Teriparatide?

Answer 7

Recombinant Human PTH Increases bone formation when given in pulses

S/E - muscle and bone pain

Question 8

Give 3 examples of bisphosphonates

Answer 8

AlenDRONic acid

RiseDRONate

ZolenDRONic acid

IbanDRONate

Question 9

How do bisphosphonates work?

Answer 9

Inhibit osteoclasts strongly

Taken on empty stomach, once/week, 4 glasses of water and nothing to eat after

Given with calcium and vitamin D supplements

S/E: GI, rare - osteonecrosis of jaw

Question 10

What is the first line medical treatment for osteoporosis?

Answer 10

Bisphosphonates - Alendronic Acid

Question 11

Give and example of a RANK ligand inhibitor used for osteoporosis treatment

Answer 11

Denosumab - Monoclonal AB, prevents osteoclast differentiation, activation and survival

Question 12

What is osteomalacia/rickets?

Answer 12

Vitamin D deficiency in adults/children leading to problem with mineralisation

A secondary cause of osteoporosis

Question 13

What are the signs for rickets? (4 marks)

Answer 13

Bowed legs

Depressed ribs

Enlarged head

Kyphosis

Question 14

What are the signs for osteomalacia? (4 marks)

Answer 14

Bone pain/tenderness

Proximal muscle weakness

Back pain

Stress fractures

Question 15

What are the levels of the following in Osteomalacia/Rickets?

… Vitamin D

… PTH

… Serum calcium

… Serum phosphate

… Alkaline phosphatase

Answer 15

Low vitamin D

Increased PTH

Normal/low serum calcium

Low serum phosphate

High alkaline phosphatase

Question 16

What is the first line treatment for vitamin D deficiency?

Answer 16

Give vitamin D (Fultium D3, Calcichew D3 Forte etc.)

Oral D2/D3 - requires good renal function

Or oral alphacalcidol (1, 25(OH) Vitamin D)

Question 17

What is Pagets Disease?

Answer 17

Disordered bone metabolism - Increased osteoclast activity, followed by osteoblast hyperactivity

This leads to “woven” mosaic bone which is weaker than normal bone

Mostly affects: Skull, Spine, Pelvis, Femur

Question 18

What are the symptoms of Pagets disease?

Answer 18

Pathological fracture

Bone pain

Sarcomatous change - rare

Indirect effects: High cardiac output, compressive effects depending on site

• Cranial nerve palsies
• Sciatica etc.

Question 19

How do you diagnose Pagets Disease?

Answer 19

X-ray

Blood tests: High alkaline phosphatase (↑ALP)

Normal: calcium, vitamin D, PTH and phosphate

Urinary hydroxyproline increased

Isotope bone scan - increased uptake of bisphosphonate

Question 20

How do you treat Paget’s Disease?

Answer 20

Only treat if symptomatic or threat of nerve compression

Treat with Bisphosphonates: Risedronate, Zolendronate