Osteoporosis

Shoban Raj a/l Vasudayan

Osteoporosis

• Bone is qualitatively normal but there is less of it than would be expected in a person of that age and sex

• WHO: Bone mineral density that is 2.5 SD below the mean peak value in young adults of the same age and sex

• Localized ( disuse / inflammation)

• Generalize Primary Secondary

Age related Osteoporosis

• Age related changes in the bone

Osteoblastic and osteoclastic activities

Estrogen withdrawal Oophorectomy MEN – 15 yrs later

• Risk factor Family history Smoking Oophorectomy Race ( Whites, Asian

>Negroid) Chronic illness Dietary

Post menopausal Osteoporosis

Clinical features• Women age of > 55• Acute back pain• Progressive kyphosis• Fractures

Involutional osteoporosis

• > 70 years old• Involve male: female

equally• # of femoral neck • # of proximal end of

humerus• Systemic disease

Diagnosis

Height lossBody weightKyphosisHumped back

Tooth loss Wall occiput distanceRib – pelvis distance

Physical examination !! Radiography

USD mesurementDEXACT scan

Investigations

• Usually obvious • Exclude other pathology if < 45 ( full inx)• Suspect osteomalacia if:

a. Multiple #b. Increased ALPc. Looser zone on X-ray

Prevention

• Maintain adequate level of dietary calcium and vit.D

• Physical activity• Avoid smoking and alcohol • Hormonal replacement therapy (HRT)• Biphosphonates

Treatment

• Manage # - internal fixation ( early mobilization)

• Mobilization + rehab

• Treat associated factorsa. Illnessesb. Dietary deficienciesc. Sunlight exposure d. Supplementse. Biphosphonate / HRT

Secondary osteoporosis

Nutritional

Endocrine disorders

Drug induced

Malignant disease

Non Malignant disease

idiopathic

RICKETS & OSTEOMALACIA

Rickets & Osteomalacia

• Different expression of the same disease • Rickets – specifically to children ( + defective

bone growth)• Osteomalacia – Bone + softening

Incomplete mineralization of the bone !!!

Vitamin DHypophosphatemia

Calcium deficiency

Comparison

Osteomalacia• Characterized by:

a. Appearance of thin trabeculae surrounded by unusually wide uncalcified osteoid.

b. Mild cases: bone looks normal

c. Severe cases: bone cortices are thinner, signs of old/ new stress #

d. Vertebral compression # are common

Rickets• Characteristic changes arise from:

a. Inability to calcify intercellular matrix

b. Cellular part of physis is thicker than normal

c. Newly formed bone in metaphysis is weak indented and cup shaped

d. Further away from physis osteomalacia changes seen

Rickets

Vitamin D deficiency• Dietary lack

• Underexposure to sunlight

• Infant – present with tetany /convulsion, Failure to thrive, muscular flacidity

• Seldom seen nowadays

Hypophosphataemic • Impaired renal tubular

reabsorption

• Calcium levels are normal but bone mineralization is defective

• Vitamin D resistant rickets (Familial hypophosphataemic rickets)

• Commonest form today

Radiography

• Bowing of long bone – femur

• Flaring of physes• Distorted metaphyseal

margin • Cupping of metaphysis• Hazy epiphyseal margin

Looser zone

• Lucent band of decreased cortical density

• Perpendicular to bone surface

Biconcave Vertebra

• Inward protrusion of intervertebral discs

Trefoil Pelvis

• Impression of sacrum and femora into pelvis

• Also known as triradiate pelvis

Investigations

• Serum Ca and phosphate are diminished• Alkaline phosphatase is increased• Urinary calcium excretion is diminished

Treatment

VIT. D Deficiency Rickets• Corrective osteotomy• Vitamin D supplement

(calciferol 400 -1000 IU per day)

Hypophosphataemic Rickets• Large dose of vitamin D (>

50,000 IU)

• Up to 4g of inorganic phosphate a day

• Bony deformity – require bracing or osteotomy

• If the child need to be immobilized Vit. D need to be stopped temporarily

Osteomalacia

• Causes ??• Lack of vitamin D• Underexposure to

sunlight• Intestinal malabsorption• Defective conversion to

active metabolites in liver or kidney

• Why no bony changes as in rickets ????

Stress #Vertebral compression #

Radiography

• Generalized rarification of bone• Si of previous # in vertebrae, ribs, pubic rami,

long bones• Looser zone

Investigations

• Serum calcium and phosphate diminished• Alkaline phosphatase is raised• Diminished 25-HCC, 1,25-DHCC• Biopsy maybe needed• Ix for underlying cause

Treatment

• Vit D + Ca supplements• Higher dose of vit D for elderly

(2000 IU/day)• Treat underlying disorder

THANK YOU ………..