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BDS3 BAMS > Rheumatology - Bone Diseases > Flashcards

Rheumatology - Bone Diseases Flashcards

1
Q

What is arthritis?

A
  • Inflammation of joints
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2
Q

What is Arthrosis?

A
  • Non-inflammatory joint disease
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3
Q

What is arthralgia?

A
  • Joint pain
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4
Q

What is Rheumatism & Rheumatic?

A
  • These terms are used in the general population but they have no medical use
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5
Q

What is bone?

A
  • A mineralised connective tissue
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6
Q

What are the 3 main features of bone?

A
  • Load bearing
  • Dynamic
  • Self-repairing
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7
Q

What does it mean by bone being ‘dynamic’?

A
  • Dynamic means that the bone is continuously changing - it does not form as a bone and then stay as a bone the same for the rest of your life
  • IT is always forming and areas of bone are being resorbed and replaced by new bone
  • This gives bone the ability to adapt to changing stresses in the environment and also allows for self-repair to take place as the processes involved in dynamic change are the same procedures which are used for repairing bone damage
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8
Q

Explain the process of bone turnover?

A
  • Bone is removed by osteoclasts and is deposited by osteoblasts
  • The osteoclasts eat away at the bone matrix and are then replaced by osteoblasts who deposit an osteoid matrix which is then mineralised to leave resting bone
  • This cycle takes place over 3-6 months
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9
Q

The right concentration of what must be present to allow bone turnover? (3)

A
  • Calcium
  • Phosphate
  • Vitamin D
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10
Q

How are calcium and bone inexorably linked?

A
  • Bone forms a store for calcium - some of which is exchangeable and some of which is not
  • The exchangeable calcium moves from the bone into the extracellular fluid and calcium is absorbed from the gut into the extra-cellular fluid
  • Calcium is lost through the gut and is also lost through the urine and it is very important for normal body function that the calcium level in the blood is maintained at a very precise level
  • This is because it is involved in nerve and muscle function
  • Therefore bone and the ECF work together and the use of parathyroid hormone helps promote the correct location of calcium
  • As an example, if there is low dietary calcium the plasma calcium could fall - in these circumstances the parathyroid hormone level will increase
  • Parathyroid hormone level will increase and will increase active vitamin D production and reduce the loss of calcium in the kidneys and will promote bone loss and the calcium will be absorbed into the extracellular fluid
    All of these will result in restoration of the normal plasma calcium level
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11
Q

Where are parathyroid glands situated?

A
  • They are situated in the thyroid gland and are at risk when thyroid surgery is carried out
  • The parathyroid hormone level is tightly maintained but can change if there are parathyroid gland tumours or if surgery accidentally removes these glands, resulting in an inability to secrete enough parathyroid hormone
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12
Q

What is the function of parathyroid hormone in relation to calcium levels? (3)

A
  • Maintains serum calcium level (raised if calcium levels fall)
  • Increases calcium release from BONE
  • Reduces RENAL calcium excretion
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13
Q

What does hypoparathyroidism result in in relation to calcium?

A
  • Low serum calcium levels
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14
Q

Hyperparathyroidism can be due to a primary or secondary cause. What is the primary cause and what will this result in in relation to calcium?

A
  • Gland dysfunction which can be because of a parathyroid gland tumour
  • This will result in a high serum calcium level and inappropriate activation of osteoclasts
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15
Q

Hyperparathyroidism can be due to a primary or secondary cause. What is the secondary cause and what will this result in in relation to calcium?

A
  • Secondary can happen when there is low serum calcium
  • In these circumstances again the parathyroid hormone levels being high, will activate osteoclasts in the bone but in this case appropriately to maintain the serum calcium level
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16
Q

What do both primary and secondary hyperparathyroidism result in in relation to bone?

A
  • Both result in increased bone reabsorption (due to the increased osteoclast activity)
  • Radiolucency’s and reabsorption (shows where the bone has been removed and resorbed)
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17
Q

How can vitamin D be absorbed into the body? (2)

A
  • This can be produced from sunlight through cholecalciferol in the skin
  • This can then be sent to the blood and processed by the liver and kidneys to form 1,25-dihydroxycolecalciferol which is the active version necessary for calcium absorption in the gut
  • Vitamin D can also be absorbed from the diet from things such as orange juice or fish
  • Both are usually part of the vitamin D production in the body
    If there are dietary peculiarities are a lack of access to sunlight this can result in low vitamin D levels and defective bone health
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18
Q

What are the possible causes of vitamin D problems? (3)

A
  • Low light exposure
  • Poor GI absorption
  • Drug interactions
  • IT is often a combination of these factors
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19
Q

One way in which we might lack vitamin D is due to low light exposure. How might this happen? (2)

A
  • Housebound (elderly)
  • Dark skinned in northern country (this is because their skin absorbs sunlight less efficiently due to the pigment in their skin)
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20
Q

One way in which we might lack vitamin D is due to poor GI absorption. How might this happen? (2)

A
  • Poor nutrition

- Small intestine disease - malabsorption

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21
Q

One way in which we might lack vitamin D is due to drug interactions. How might this happen? (2)

A
  • Sometimes drugs can interfere with the Vitamin D synthesis
  • Some antiepileptic drugs (Carbamazepine, Phenytoin)
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22
Q

What is Osteomalacia?

A
  • This is a condition where bone is formed normally and normal osteoid matrix is formed but this is not calcified properly, therefore there are normal amounts of osteoid but inadequate mineralisation of the tissue (this will make it soft and more pliable)
  • Poorly mineralised osteoid matrix
  • Poorly mineralised cartilage growth plate
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23
Q

What is osteoporosis?

A
  • In Osteoporosis the mineral and the matrix are correct but there is less of it and therefore the correct bone mass is not achieved even though the bone which is present is normally mineralised
  • Loss of mineral matrix - reduced bone mass
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24
Q

If Osteomalacia occurs during bone formation, what is it called?

A
  • Rickets
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25
Q

If Osteomalacia occurs after bone formation is complete what is it called?

A
  • Osteomalacia
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26
Q

Osteomalacia is related to a deficiency in what?

A
  • Related to a calcium deficiency
  • Serum calcium preserved at expense of bone mineralisation
  • Therefore when calcium is in short supply during bone formation, the bones which are produced are soft and can bend to pressure - this is seen in rickets
27
Q

What are the effects of Osteomalacia on bones? (2)

A

Bones bend under pressure

  • Bow legs in children with Rickets
  • Vertebral compression in adults
  • Bones Ache to touch
28
Q

What are the hypocalcaemia effects of osteomalacia (when inadequate calcium is present)?

A
  • Muscle weakness
  • Trosseau & Chvostek signs positive
  • Carpal muscle spasm
  • Facial twitching from VII trap
29
Q

In Osteomalacia what are serum calcium levels like?

A

Decreased

30
Q

In osteomalacia what are serum phosphate levels like?

A

Decreased

31
Q

In Osteomalacia what are alkaline phosphatase levels like?

A
  • Very high

- Alkaline phosphatase is a measure of bone turnover and is very high when there is a problem with the calcium levels

32
Q

In osteomalacia what are the Plasma creatine levels like?

A
  • They are increased if it is a renal cause
33
Q

In osteomalacia what are the plasma parathyroid hormone levels like?

A
  • Increased if secondary hyperparathyroidism
34
Q

How might we manage Osteomalacia? (3)

A

Correct the cause:

  • Malnutrition (control GI disease)
  • Sunlight exposure (30 mins 5x weekly)
  • Dietary Vitamin D supplement
35
Q

What can be the easiest way to restore vitamin D deficiencies these days?

A
  • Using a Dietary Vitamin D supplement
36
Q

What is Osteoporosis?

A
  • It is a REDUCED QUANTITY of normally mineralised bone
37
Q

Is osteoporosis age related?

A
  • Yes and it is inevitable in all people
38
Q

Give examples of some general risk factors of osteoporosis? (6)

A
  • Age
  • Female sex
  • Endocrine
  • Genetic
  • Patient factors
  • Medical drug use
39
Q

Give examples of endocrine risk factors for osteoporosis? (2)

A
  • Oestrogen and Testosterone Deficiency

- Cushing’s syndrome (increased corticosteroid levels in the blood)

40
Q

Give examples of genetic risk factors for osteoporosis? (3)

A
  • Family History
  • Race - Caucasian & asian women
  • Early menopause
41
Q

Give examples of patient factor risk factors for osteoporosis? (4)

A
  • Inactivity
  • Smoking
  • Excess alcohol use
  • Poor dietary calcium
42
Q

Give examples of medical drug risk factors for osteoporosis? (2)

A
  • Steroids
  • Antiplatelets

(these can affect calcium metabolism)

43
Q

When is a persons peak bone mass?

A
  • Peak bone mass is at age 24-35 years
  • Osteoporosis will be found in years heading away from that and the longer that you live the higher the chances that you will get this
44
Q

What % of women aged 50 is osteoporosis found?

A

15%

45
Q

What % of women aged 70 is osteoporosis found?

A

30%

46
Q

What % of women aged 80 is osteoporosis found?

A

40%

47
Q

What is the link between osteoporosis and gender?

A
  • When we look at osteoporosis and gender it is very clear why osteoporosis is more of an issue in women and that is because traditionally the peak bone mass in the skeleton is lower in women than in men
  • It is artificially boosted by oestrogen but as oestrogen is lost during the menopause that protection is lost and there is rapid loss of bone mass
  • Although after this the rate of decline continues at a normal rate
  • In men the rate of decline is similar but the peak is higher and therefore as osteoporosis clinical effects are not based upon the changes relative to the peak bone mass but your absolute peak bone mass - it takes longer for men to loose enough bone mass to reach the osteoporosis point than it does for women
  • Therefore men do get osteoporosis but it is just not as common
48
Q

In osteoporosis bone mass may no longer be adequate to maintain the stresses applied to the bone and therefore what is there an increased risk of?

A
  • Increased bone fracture risk
  • This is likely in long bones e.g. femur
  • But also true for bones for example in the wrist where if the patient should fall onto their outstretched arms, this sudden application of force to the wrist causes fracture
49
Q

What are the effects of osteoporosis on the vertebrae? (3)

A
  • Height loss
  • Kyphosis & scoliosis
  • Nerve root compression - back pain
50
Q

What is Kyphosis?

A
  • The bending forward of the spine as the vertebral bodies collapse under the weight of the upper body, causing tipping
51
Q

What is scoliosis?

A
  • A shifting of the lateral position of the vertebrae caused by compression
52
Q

What is the lifetime risk of hip fracture in women >50 years of age with osteoporosis?

A

17.5%

53
Q

What is the lifetime risk of hip fracture in men >50 years of age with osteoporosis?

A

6%

54
Q

After an osteoporosis related hip fracture What is the % increase in 5yr mortality?

A
  • 20% increase

- Maximal in initial 6 months following surgery

55
Q

After an osteoporosis related hip fracture what % of patients are unable to walk unaided?

A

40%

56
Q

After an osteoporosis related hip fracture what % of patients are unable to live independently?

A

60%

57
Q

One way to prevent osteoporosis is to build a maximal peak bone mass. How might we do this and why does it help?

A
  • Exercise
  • High dietary calcium intake
  • This means when osteoporosis inevitably happens, because it is starting from a higher initial point, the time taken to get to an effective clinical problem will be longer
58
Q

One way to prevent osteoporosis is to reduce the rate of bone mass loss. How would we do this? (4)

A
  • Continue exercise and calcium intake throughout life
  • Reduce hormone related effects (oestrogen hormone replacement therapy - most effective if early menopause)
  • Reduce drug related effects
  • Consider ‘osteoporosis prevention’ drugs - bisphosphonates
59
Q

What does oestrogen only hormone replacement therapy reduce the risk of? (2)

A
  • Reduces osteoporosis risk
  • May reduce ovarian cancer risk
  • Benefit lost after HRT stopped - 5yrd post treatment BMD ‘normal’
60
Q

What does oestrogen only hormone replacement therapy increase the risk of? (3)

A
  • Increases breast cancer risk
  • Increases endometrial cancer risk (patients who have NOT had a hysterectory) - combine with progesterone to reduce risk
  • Increases DVT risk
61
Q

Give examples of non-nitrogenous bisphosphonates? (3)

A
  • Etidronate
  • Clodronate
  • Tildronate
62
Q

Give examples of nitrogenous bisphosphonates? (7)

A
  • Pamidronate
  • Neridronate
  • Olpadronate
  • Alendronate
  • Ibandronate
  • Risedronate
  • Zoledronate
63
Q

What are bisphosphonates?

A
  • They act by preventing osteoclast action by poisoning the osteoclasts and reducing their numbers
  • If there are reduced osteoclasts less bone can be removed and therefore the bone mass will be preserved
  • There are 3 main drugs we will come across: Alendronate, Ibandronate and Zoledronate
  • The numbers to the side are the potencies of these drugs relative to the original bisphosphonate etidronate
  • And so we can see that these later drugs are extremely potent such that zoledronate only has to be given once every year for osteoporosis prevention - that action is enough to keep the patients bone mass in check
64
Q

Give the benefits of using Alendronate or Risedronate in an osteoporosis risk population? (4)

A
  • Reduce vertebral fracture risk by 50%
  • Reduce other fractures by 30-50%
  • Benefit lost if drug discontinued
  • Can be combined with HRT

BDS3 BAMS (11 decks)

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