Metabolic Bone Disease

Question 1

Osteoporosis two types:

Answer 1

Primary (type 1 and type 2) and secondary

Question 2

Primary osteoporosis includes

Answer 2

type 1 - postmenopausal most prevalent form (females 50-70yo)
type 2 - senile (age related, men and women > 70yo)

Question 3

Secondary osteoporosis includes

Answer 3

malignancies, long term corticosteroid use, GI disorders, hormonal imbalances

Question 4

Osteoporosis and osteopenia is

Answer 4

bone becomes weak and brittle, increased osteoclast or decreased osteoblast activity
end result = impaired bone structure, disorder skeletal architecture

Question 5

Osteoporosis and osteopenia risk factors

Answer 5

EtOH, smoking, low body wt, sedentary lifestyle, low Ca, low Vit D, corticosteroid use

Question 6

Osteopenia and osteoporosis presentation

Answer 6

usual presentation is via screening or fragility fractures - vertebrae > hip > pelvis > others
might see hyperkyphosis and/or ht loss (can be related to compression fractures)

Question 7

What are fragility fractures?

Answer 7

any fracture that results from low-energy that wouldn’t otherwise produce a fracture in an otherwise healthy adult
fall from standing ht or less or no identifiable trauma

Question 8

Screening for osteoporosis and osteopenia

Answer 8

Gold standard for screening is dual-energy x-ray absorption (DEXA) - reported as T-scores

Question 9

Bone Density testing indications

Answer 9

ALL women (post menopausal) > 65, men > 70
Post/Perimenopausal women with clinical risk factors, hx of prior fracture
Anyone with a fragility fx
Pts with RA
Anyone with risk factors

Question 10

DEXA measurement measures

Answer 10

bone density measurement - lumbar spine L1-4, femoral neck, total femur (hip)

Question 11

T or Z score of -1 to -2.5 =

Answer 11

osteopenia

Question 12

T or Z score of less than -2.5 =

Answer 12

Osteoporosis

Question 13

T-score less than -2.5 with fracture =

Answer 13

severe osteoporosis

Question 14

Repeat DEXA scan based on T score:
T score of -1 - -1.5 =
T score of -1.5 - 02.0 =
T score of -2.0 =

Answer 14

every 5 years
every 3-5 years
every 1-2 years

Question 15

What tests do you ALWAYS want to check for osteomalacia?

Answer 15

Vit D
Co-occuring Vit D deficiency common

Question 16

What is the BEST treatment for osteoporosis?

Answer 16

PREVENTION (first line)

Question 17

What are some preventative strategies?

Answer 17

Wt bearing/ resistance exercise
Fall prevention strategies
Adequate dietary Ca or Ca supplementation and dietary Vit D or Vit D supplementation
Reduce Corticosteroids if possible, smoking cessation, ETOH reduction
fall prevention

Question 18

Osteoporosis/ osteopenia replacement/ supplementation that is recommended

Answer 18

Calcium replacement/ supplementation
Recommended: 1200 mg daily
Vit D - 1000-2000 units daily

Question 19

Who gets Osteoporosis/osteopenia treatment based on T score

Answer 19

T score of less than or equal to -2.5
Osteopenia and 10 year hip fracture risk > 3%
10 year major fracture risk of > 10%
Any patient with a fragility fracture

Question 20

Osteopenia/ Osteoporosis Pharmacologic treatment Options

Answer 20

Cal + Vit D
Bisphosphonates (outside of Vit supplementation this is first line) = usually Alendronate or risedronate

Question 21

Bisphosphonate Side effects

Answer 21

abdominal pain, heartburn, esophageal irritation, ulcers, osteonecrosis of the jaw

Question 22

Osteomalacia is a

Answer 22

disorder of the bone, characterized by decreased mineralization of newly formed osteoid at sites of bone turnover
secondary to increasing Vit D deficiency in adults - affects bones only

Question 23

Rickets is

Answer 23

Vit D deficiency or defect in Vit D metabolism in children - affects bones and cartilages

Question 24

Other vit that might be causing Osteomalacia or Rickets besides Vit D

Answer 24

calcium
phosphate deficiency or aluminum toxicity

Question 25

Medications that might cause osteomalacia

Answer 25

Phenytoin carbamazepine valproate barbiturates

Question 26

Vit D deficiency Etiology

Answer 26

lack of sunlight lack of fortified foods absorption problems

Question 27

Osteomalacia/ Rickets presentation

Answer 27

diffuse muscle weakness, esp pelvic girdle bone pain waddling gait fractures following minor or no trauma Rickets - children develop permanent skeletal deformities

Question 28

Osteomalacia workup

Answer 28

bone density measurement - generalized decreased bone bx bloodwork - vit d low, calcium phosphate low, alkaline phosphatase high, secondary hyperparathyroidism

Question 29

Osteomalacia on xray

Answer 29

Milkman lines or Looser zones (Looser-Milkman pseudofractures) are dx but not always present

Question 30

Osteomalacia treatment

Answer 30

High dose Vit D Phosphate supplementation and Vit D in renal phosphate wasting Ca supplementation Discontinue aluminum-containing antacids Prophylactic treatment for pts on phenytoin

Question 31

Paget's Disease of Bone is

Answer 31

metabolic bone disease inflammatory disorder of the bone - accelerated rate of bone remodeling resulting in overgrowth of bone in aging skeleton

Question 32

Paget's Disease of Bone presentation

Answer 32

Often asymptomatic - may be incidental finding on Xray enlarged, misshapen bones, bowed tibia, kyphosis sx - bone and joint pain, HA, hearing loss, nerve root impingement, cauda equina (Neuro complications involving skill/spine compression)

Question 33

Diagnosis of Paget Disease of the Bone

Answer 33

calcium and phosphate - normal PTH - usually elevated Alkaline phosphatase - high (liver enzyme, marker of high bone turnover) Hypercalciuria common

Question 34

Paget's disease of bone dx is made primarily via

Answer 34

radiographs (xray and bone scans usually dx)

Question 35

Skeletal findings of Paget's Disease of Bone

Answer 35

curved long bones (bowed) Cotton ball appearance of skull picture frame appearance in spine if lesions suspicious for malignancy --> bone bx

Question 36

Paget's disease of the bone treatment

Answer 36

Mainstay of treatment is bisphosphonates --> inhibits osteoclasts - IV zolendronic acid (Reclast) most effective ensure adequate Ca and Vit D - all don't need supplementation

Question 37

Osteogenesis Imperfecta is a

Answer 37

rare bone disorder - 'brittle bone disease' Genetic disorder - decreased or impaired type 1 collagen --> insufficient osteoid --> impaired remodeling

Question 38

Osteogenesis Imperfecta presentation

Answer 38

MSK manifestations: fragile bones (multiple fx minimal trauma, reduces as pt gets older stops after puberty) deformities (fx heal initially but can't remodel) bowing of long bones scoliosis short stature ligamentous laxity

Question 39

Osteogenesis Imperfecta non-MSK manifestations:

Answer 39

Blue sclera hearing loss brownish opalescent teeth (teeth) think skin hypermetabolism

Question 40

Osteogenesis Imperfecta dx

Answer 40

skin bx - abnormal collagen genetic testing (before/after birth)

Question 41

Osteogenesis Imperfecta treatment

Answer 41

best treatment is prevention of fractures exercise & PT to strengthen muscles/bones Prophylactic rods to prevent long bone fractures bracing for fracture prevention