15/10/2025
๐ Osteoporosis:
A systemic skeletal disorder characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to increased bone fragility and susceptibility to fractures.
๐ Cause / Pathophysiology:
โข Imbalance between bone resorption (osteoclast activity) and bone formation (osteoblast activity).
โข Estrogen deficiency (postmenopause) โ accelerates bone loss.
โข Age-related decline in bone mass and quality.
โข Secondary causes: corticosteroid use, hyperthyroidism, hyperparathyroidism, chronic kidney disease, alcohol, smoking, malnutrition, immobilization.
โข Bone mineral density (BMD) decreases โ increased risk of fragility fractures (hip, vertebrae, wrist).
โ Epidemiology:
โข Most common metabolic bone disease worldwide.
โข More prevalent in women (especially postmenopausal) than men.
โข Significant morbidity and mortality associated with hip and vertebral fractures.
โข Incidence rises sharply after age 50.
๐ Clinical Features:
โข Often asymptomatic until fracture occurs.
โข Typical fracture sites: vertebral compression fractures, hip fractures, distal radius (Collesโ fracture).
โข Vertebral fractures โ height loss, kyphosis (โdowagerโs humpโ), chronic back pain.
โข May present with acute pain after minimal trauma or spontaneous fractures.
โข Risk factors: advanced age, female s*x, low BMI, family history, sedentary lifestyle, chronic steroid use, smoking, alcohol.
๐ Investigations / Diagnosis:
โข DXA scan (dual-energy X-ray absorptiometry):
โข Gold standard for measuring BMD.
โข T-score โค โ2.5 at femoral neck, total hip, or lumbar spine = osteoporosis.
โข T-score between โ1.0 and โ2.5 = osteopenia.
โข Laboratory work-up: rule out secondary causes (calcium, phosphate, vitamin D, renal/liver function, TSH, PTH).
โข X-ray: vertebral compression fractures, but not sensitive for early disease.
โข FRAX score: estimates 10-year fracture risk using clinical risk factors ยฑ BMD.
๐จ Clinical Importance (ED perspective):
โข Patients may present with fragility fractures after minor trauma (ground-level fall).
โข Vertebral compression fractures may present with sudden severe back pain, reduced mobility, or progressive height loss.
โข Hip fractures in elderly โ high morbidity, immobility complications (DVT, pneumonia), and increased 1-year mortality.
โข Consider underlying osteoporosis in any patient >50 with low-trauma fracture.
๐ Treatment / Management:
Acute / Emergency Department:
โข Pain control (acetaminophen, NSAIDs if not contraindicated, opioids if severe).
โข Immobilization and referral for fracture management (orthopedic).
โข Identify red flags: neurologic deficits (spinal cord compression), pathologic fractures from malignancy.
Long-Term Management (outpatient):
โข Lifestyle: weight-bearing exercise, smoking cessation, limit alcohol, fall-prevention strategies.
โข Calcium & Vitamin D supplementation: Calcium 1000โ1200 mg/day; Vitamin D 800โ1000 IU/day.
โข Pharmacologic therapy:
โข First-line: Bisphosphonates (alendronate, risedronate, zoledronic acid).
โข Alternatives: Denosumab (RANKL inhibitor), SERMs (raloxifene), Teriparatide (PTH analog, anabolic), Romosozumab (sclerostin inhibitor, anabolic), Hormone replacement (selective cases).
โข Monitoring: repeat DXA every 1โ2 years.
๐งญ Disposition & Follow-Up:
โข ED role: treat acute fractures, ensure safe discharge/transfer, recommend evaluation for osteoporosis after fragility fracture.
โข Referral: endocrinology, rheumatology, or primary care for metabolic bone work-up.
โข Educate patients: adherence to therapy and fall-prevention strategies crucial.
