1-19 Diagnosis And Risk Factors of Osteoporosis 2004

8/14/2019 1-19 Diagnosis And Risk Factors of Osteoporosis 2004

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DIAGNOSIS AND RISK FACTORSDIAGNOSIS AND RISK FACTORSOF OSTEOPOROSISOF OSTEOPOROSIS

BY

PROFESSORHAZEM ABDEL AZEEM

CAIRO UNIVERSITY

March 2004


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OSTEOPOROSISOSTEOPOROSIS

A systemic skeletal disease:

Low bone mass

Microarchitecture deterioration of bone

tissue

Increased bone fragility and susceptibility

to fractures


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OsteoporoticBone LossOsteoporoticOsteoporoticBone LossBone Loss

NormalOsteoporosis

Dem psterDW , et al.J Bone Min Res. 1986;1:15-21.

Reprinted with permission from the American Society for Bone andMineral Research.


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Relationship of

causes ofosteoporosis to

balance of bone

remodelling


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CAUSES OF OSTEOPOROSISCAUSES OF OSTEOPOROSIS


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RISK FACTORS OFRISK FACTORS OF

OSTEOPOROSISOSTEOPOROSIS Age.

Sex.

Genetic. Lifestyle

Nutritional.

Medical disorders.

Drugs.

Previous fracture.


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Age-related changesAge-related changes

After age 60, subperiosteal

area slowly increases but

medullary cavity enlarges

faster, resulting in net

decrease of cortical

thickness and mass


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Gender related factors (female)Gender related factors (female)

Prolonged amenorrhoea: Anorexia nervosa

Exercise induced

Prolactinoma

Premature menopause (15 years)


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Genetic factorsGenetic factors

White or asiatic ethnicity

Family (maternal) history of fractures

Paternal family history of hip fracture

Small body frame

Tallness

Premature greying of hair

Fair skinned

Blue eyed


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LifestyleLifestyle

Nulliparity

Coffee

Smoking

Alcohol intake

Parity

Prolonged breast-feeding

Inactivity


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NutritionalNutritional

High Na diet

High protein diet

High phosphate diet

Animal fat

Leanness


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DRUGS RELATED RISKSDRUGS RELATED RISKS

Smoking

Glucocorticoids and

ACTH

Thyroxine

Anticonvulsants

Heparin

Lithium

Cytotoxic

Gonadotrophin-RH

agonists

Tamoxifen

Medroxyprogester-

one acetate Aluminium

Excess Vitamin D

Drugs causing falls Hyperoxia


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Effects of smokingEffects of smoking

Accelerated menopause

Decreased fat mass

-- peripheral production of oestrogen

-- resistance to falls -- weight on skeleton

++ metabolism of endogenous oestrogen

++ metabolism of exogenous oestrogen

Association with alcohol consumption and other

life-style factors


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Target tissue Action Effect

Osteoblasts

Recruitment

Osteocalcin (rapid)

Collagen synthesis

Formation

Adrenals & gonads

Parathyroid

Gut

Renal tubule

Gonadal hormones

Sensitivity to Vit. D

Secretion

Calcium reabsorption

Resorption

Bone loss

Muscle

Bone: immobilization

Skeletal load

?

EFFECTS OF

GLUCOCORTICOIDS


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HeparinHeparin

A likely direct effect on osteoclast

development and activation

Substantial doses required (10-15000 units

daily) Rates of bone loss may be rapid

Vertebral and rib fractures

Doses in haemodialysis are too low

Calcitonin and anabolic steroids may be

preventive


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Coffee (Caffeine)Coffee (Caffeine)

Can increase urinary excretion rate

of calcium

For osteoporosis: data are

circumstantial and not convincing

Association between coffee and hip

fracture are not consistent


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Alcohol excessAlcohol excess

Significant risk factor especially in men Effect:

Direct (++resorption/--formation)

Associated with protein undernutrition

Changes in life style Liver disease

Decrease in Testosterone

Increase risk of falls

In healthy individuals

decrease secretion of PTH

increase secretion of calcitonin


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High Sodium IntakeHigh Sodium Intake

Decreases tubular reabsorption of Ca due

to co-transport mechanism

This may induce secretion of PTH There is increase in urinary cAMP

Long-term experimental and

epidemiological studies provide littleevidence that variations in the normal

intake of Na affect skeletal mass


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Assessment of osteoporosis (aim)Assessment of osteoporosis (aim)

Diagnosis.

Identification of disorders mimicking

osteoporosis.

Identification of risk factors.

Methodology for prognosis.

Selection of treatment.

Baseline for response evaluation.


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DIAGNOSIS OF OSTEOPOROSISDIAGNOSIS OF OSTEOPOROSIS

CLINICAL DIAGNOSIS.

RADIOLOGICAL DIAGNOSIS.

LABORATORY DIAGNOSIS.

BONE DENSITOMETRY.

BONE BIOPSY.


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CLINICAL DIAGNOSISCLINICAL DIAGNOSIS

History of positive risk factors.

Clinical presentation:

Loss of height. Diffuse kyphosis.

Pains.

Fractures.

Worry and psychic effects.


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LOSS OF HEIGHTLOSS OF HEIGHT

VERTEBRAL COMPRESSION.

VERTEBRAL WEDGING.

LOWER LIMB BONES BOWING.


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KYPHOSISKYPHOSIS

DIFFUSE.

DORSAL.

DORSO-LUMBAR.

SLOWLY PROGRESSIVE.


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PAINSPAINS

MICROFRACTURES.

LONG STANDING KYPHOSIS.

ASSOCIATED OSTEOMALACIA.

OSTEOPOROTIC FRACTURES.

MUSCULAR. FIBROMYOSITIS.


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FRACTURESFRACTURES FRAGILITY FRACTURES.

MINOR TRAUMA. COMMON SITES:

Spine.

Proximal end of femur.

Distal end of radius.

Proximal end of humerus.


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Washed-out

vertebrae without

vertebral collapse

or kyphosis

Anterior wedge

compression with

kyphosis

Severe kyphosis in postmenopausal

woman. Mild, multiple biconcavity and

wedging of vertebrae.


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Primary axial osteoporosisPrimary axial osteoporosis

65 year-old female with a few years history of pain in the back


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Fracture Neck of FemurFracture Neck of Femur

75 year-old female with a frail constitution, hospitalized in an institution for

chronic diseases; fractures of the right neck of femur at the age of 68,

intertrochanteric fracture at 72, in both instances due to a slight fall.


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Fracture of the neck of theFracture of the neck of the

humerushumerus

77 year-old peasant woman. She was

being treated for an axial osteoporosis.

She wakes up in the morning with pain in

the shoulder and limitation of movement.

She has fracture of the anatomical neck of

the humerus, and the greater trochanter

with abduction displacement of the shaft in

relation to the elevated head.


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Radiographic findings inRadiographic findings in

osteoporosisosteoporosis

AB + CD >/=

medulla

AB+CD/XY >/=

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In ostepenia 1.0Osteopenia 1.0 to2.5(low bone mass)

Osteoporosis 2.5Severe (established) osteoporosis 2.5 with fracture

WHO = World Health Organization; NOF = National Osteoporosis Foundation.

Physicians Guide to Prevention & Treatmen t of Osteoporosis, 1998

Bone mass T-score: The standard deviation in a patients bone m ineral density

(BMD) compared with the peak bone mass in a young adult of the same gender

NOF/WHO Criteria for Assessing

Disease Severity

NOF/WHO Criteria for AssessingNOF/WHO Criteria for Assessing

Disease SeverityDisease Severity


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Quantitative UltrasoundQuantitative Ultrasound

Recent widespread attention:

no radiation

relatively simple to implement and process

portable

inexpensive

may measure additional bone properties as

mechanical integrity

Accessible sites: the calcaneus, the patella, the

radius, tibia and phalanges


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Quantitative UltrasoundQuantitative Ultrasound

(contd.)(contd.) Ultrasound assessment is based on:

velocity of ultrasound wave

attenuation of ultrasound wave Propagation of wave is affected by:

bone mass

bone architecture

directionality of loading

At the calcaneus, correlation with DEXA is 0.80 to

0.85


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Bone BiopsyBone Biopsy


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Bone BiopsyBone Biopsy

Red-stained osteoid seams lined

with OB (osteblasts) and OC

(osteoclasts) versus poor osteoidseams and little osteoblasts and

osteclasts in bone resorption

Tetracycline labeling on fluorescent

microscopy showing normal bone with

yellow lines at mineralization front versusabsence of bone formation.

T= bone trabecula M= marrow


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1-19 Diagnosis And Risk Factors of Osteoporosis 2004

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