Osteoporosis Summary

Definitions

  • Osteoporosis: BMD T-score ≤ -2.5
  • Fragility fracture: From standing height fall
  • Osteoporotic fracture: Due to osteoporosis

Major Risk Factors

  • Age >50 years
  • Previous fragility fracture
  • Oral corticosteroids
  • Family history of hip fracture
  • Early menopause

Assessment

  • DXA scan for BMD measurement
  • QFracture® or FRAX® risk calculation
  • Exclude secondary causes
  • Vitamin D and calcium assessment

First-line Treatment

  • Bisphosphonates (alendronate/risedronate)
  • Calcium + Vitamin D supplementation
  • Lifestyle modifications
  • Fall prevention strategies

Common Fracture Sites

  • Vertebral (most common)
  • Hip
  • Wrist (Colles')
  • Proximal humerus

Risk Stratification

  • High risk: DXA + treatment if T ≤ -2.5
  • Intermediate: DXA, treat if T ≤ -2.5
  • Low risk: Lifestyle advice, follow-up

Critical Points

  • Often asymptomatic until fracture
  • Rule out malignancy in atypical cases
  • HRT for premature menopause
  • Regular exercise crucial

Osteoporosis and Fragility Fracture

Comprehensive guide to bone health assessment, prevention, and management

Overview

Osteoporosis is a disease characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Osteoporosis is the end result of an imbalance in the normal process of bone remodelling by osteoclasts and osteoblasts. It is asymptomatic and often remains undiagnosed until a fragility fracture occurs.

Key point: Osteoporosis is often a "silent disease" until the first fracture occurs, making prevention and early detection crucial.

Definitions

Osteoporosis

Defined by the World Health Organization as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass (average of young healthy adults) as measured by dual-energy X-ray absorptiometry (DXA) applied to the femoral neck and reported as a T-score.

Osteoporotic Fracture

A fragility fracture occurring as a consequence of osteoporosis. Osteoporotic fractures characteristically occur in the wrist, spine and hip, but can also occur in the arm, pelvis, ribs and other bones.

Fragility Fracture

Defined as a fracture following a fall from standing height or less, although vertebral fractures may occur spontaneously, or as a result of routine activities such as bending or lifting.

Risk Factors

The risk of getting an osteoporotic fracture depends on the person's risk of falls, their bone strength (determined by bone mineral density), and other risk factors.

Risk Factors Affecting Bone Strength

Reduce BMD

  • Endocrine disease (diabetes mellitus, hyperthyroidism, hyperparathyroidism)
  • Malabsorptive disease (IBD, coeliac disease, chronic pancreatitis)
  • Chronic kidney disease
  • Chronic liver disease
  • COPD
  • Menopause
  • Immobility
  • BMI < 18.5 kg/m²

Do Not Reduce BMD

  • Age
  • Oral corticosteroids
  • Smoking
  • Alcohol
  • Previous fragility fracture
  • Rheumatological disease (rheumatoid arthritis)
  • Parental history of hip fracture

Other Risk Factors

Unestablished Mechanisms

  • Selective serotonin reuptake inhibitors (SSRIs)
  • Proton pump inhibitors (PPI)
  • Anticonvulsant drugs (carbamazepine)

Risk Factors for Falls

  • Impaired vision
  • Neuromuscular weakness and incoordination
  • Cognitive impairment
  • Use of alcohol and sedative drugs

Assessment for Fragility Fracture Risk

Exclusion of Other Conditions

Important: Exclude non-osteoporotic causes for fragility fractures:

  • Metastatic bone disease: Bone pain, history of cancer, unexplained malaise or weight loss
  • Multiple myeloma: Bone pain, anaemia, recurrent infection, hypercalcaemia
  • Osteomalacia: Bone pain, muscle pain or proximal muscle weakness
  • Paget's disease: Bone pain or deformity
  • Aneurysmal bone cyst or hemangioma
  • Infection: Osteomyelitis, Pott's disease

DXA Scan Indications

Direct DXA Without Risk Calculation

  • Over 50 years with history of fragility fracture
  • Younger than 40 years with major risk factor

Risk Calculation First

  • All other people with risk factors
  • Use QFracture® (preferred) or FRAX®
  • Predicts 10-year fracture risk

Risk Stratification and Management

Risk Category Management
High Risk
(Above threshold)		 Offer DXA scan → drug treatment if T-score ≤ -2.5
If T-score > -2.5: modify risk factors, repeat DXA within 2 years
Intermediate Risk
(Close to threshold)		 Arrange DXA scan → drug treatment if T-score ≤ -2.5
Low Risk
(Below threshold)		 Do not offer drug treatment, lifestyle advice, follow-up within 5 years

Vitamin D and Calcium Assessment

  • Vitamin D deficiency risk: Age >65 years, limited sun exposure, full-body clothing
  • Calcium intake: At least 1000 mg/day recommended for high-risk individuals

Management

Lifestyle Advice

Essential Recommendations

  • Take regular exercise to improve muscle strength
  • Eat a balanced diet
  • Stop smoking if needed
  • Drink alcohol within recommended limits

Bone-Sparing Treatment

First-line Therapy

  • Bisphosphonates:
    • Alendronate 10 mg daily or 70 mg weekly
    • Risedronate 5 mg daily or 35 mg weekly
  • For postmenopausal women and men >50 with confirmed osteoporosis (T-score ≤ -2.5)

Special Considerations

  • Consider for high-dose oral corticosteroids (>prednisolone 7.5 mg daily for ≥3 months)
  • Specialist options: Zoledronic acid, strontium ranelate, raloxifene, denosumab, teriparatide

Calcium and Vitamin D Supplementation

Situation Supplementation
Adequate calcium intake (≥700 mg/day) Vitamin D 10 mcg (400 IU) daily
Inadequate calcium intake Vitamin D 10 mcg (400 IU) + Calcium 1000 mg daily
Elderly, housebound, nursing home Vitamin D 20 mcg (800 IU) + Calcium 1000 mg daily

Hormone Replacement Therapy

Consider prescribing hormone replacement therapy (HRT) to women who have a premature menopause (menopause before 40 years of age) to reduce the risk of fragility fractures and for the relief of menopausal symptoms.

Vertebral Compression Fractures

Vertebral compression fractures are the most common type of osteoporotic fracture. They often occur at the midthoracic (T7-T8) spine and the thoracolumbar junction (T12-L1).

Clinical Presentation

Symptoms

  • Acute back pain after sudden bending, coughing, or lifting
  • Pain localised to midline spine
  • Referred pain to flank, abdomen, or iliac spine
  • Height loss or kyphosis (chronic cases)

Examination Findings

  • Pain on palpation/percussion of spinous process
  • Paravertebral muscle tenderness
  • Limited spinal mobility
  • Often no history of significant trauma

Management

Acute Phase (4-6 weeks)

  • Pain control
  • Activity modification
  • Avoid bed rest
  • Gradual return to normal activities

Chronic Phase

  • Most resolve with conservative management
  • Persistent pain may indicate unhealed fracture
  • Consider vertebral augmentation if conservative measures fail
  • Address underlying osteoporosis

Complications: Vertebral fractures can lead to significant back pain, limited physical functioning, loss of independence, depression, and chronic pain. Early intervention and comprehensive management are crucial.