DR. Leena Abdulla
Family Medicine Consultant.
Dr Khalid Al-Karbi PGY 2
• Case history: 68-year-old white woman
• Presents to accident and emergency department
with right wrist pain, swelling, and displacement
following a fall onto outstretched hand on the
stairs at home
• Past medical history – asthma since childhood (treated
with corticosteroids aged 50–55), gastric ulcer aged 45,
menopause age 59, left wrist fracture aged 67
• Family history – stroke in sister aged 65, hip fracture in
mother aged 78. Mother diagnosed with osteoporosis
• Social history – lives alone, 2 children, retired, smokes 5
cigarettes per day, occasional alcohol, takes no exercise,
fully mobile and able to complete all ADLs (activities of daily
• On examination – wrist displaced, swollen, no
• No loss of sensation or vascular compromise
• X-ray – Colles’ fracture of distal radius present
A tip to remember
• N.B. The most common osteoporotic fractures are
vertebrae, wrists, and hips. Lifetime risk of fracture
in white women is 20% for spine, 15% for wrist,
and 18% for hip. There is an exponential increase
in fracture over 50 years
F. 19-year-old presented with difficulty in
walking for many years, especially going
upstairs. She felt parasthesia in hands & feet
and occasional spasm. P/E: waddling gait.
Ca: 1.8 mmol/l (2.1-2.6) P: 0.54 mmol/l (0.7-
1.4). Alk Phos: 562 ( - 125).
• What other test results you need?
Educational Objectives :
• Understand the difference between osteomalacia and
• Identify the following aspects of osteomalacia and
- Risk factors
- Clinical picture
- Prevention and Treatment.
Terms to remember
• Osteoclasts: bone resorption, stimulated
• Calcitonin: inhibits osteoclastic bone
• Slow down of bone build up: osteoporosis seen in
older women and men (men after age 70)
• Accelerated bone breakdown: postmenopausal
• Normal loss 0.5% per year after peak in 20s
• Up to 5% loss/year during first 5 years after menopause
What is Osteoporosis?
• “Systemic skeletal disease characterized by low bone
mass and microarchitectural deterioration of bone
tissue, leading to enhanced bone fragility and a
consequent increase in Fracture risk”
• True Definition: bone with lower density and higher
• WHO defines Osteoporosis as; Bone Mineral Density
as definition (T score <-2.5); surrogate marker
Changes in bone mass with age
0 10 20 30 40 50 60 70 80
Adapted from J Compston 1990
Peak bone mass
The Epidemiology and the
Burden of the disease.
• In the U.S., more than 10 million persons over age
50 are affected by osteoporosis, and
approximately 33.6 million have osteopenia.
• The lifetime risk of osteoporotic fractures is
approximately 50% for women and 30% for men.
• However, the mortality rate following all types of
fractures is much higher in men than in women
Annual Incidence of Osteoprosis in
comparison to major morbidities
affecting elder women
Parent broke their hip
Body mass index
Alcohol >3 units
Risk of a fragility fracture
• Females are at greater risk of developing
• The frequency of postmenopausal osteoporosis is
highest in women aged 50-70 years.
• Senile osteoporosis is most common in persons aged
70 years or older.
• Wrist fractures are usually the 1st presentation (6th
decade of life).
• The majority of hip fractures happens by the 9th
decade of life.
• Secondary osteoporosis :
- Hypogonadal states
- Endocrine disorders
- Deficiency states
- Inflammatory diseases
- Hematologic and neoplastic disorders
• A prominent finding in patients with fractures is point
• Low body weight (< 127 lb [58 kg]) associated with
• Physical examination may show signs of vertebral
compression, such as kyphosis, height loss (>1.5 cm),
or a protruding abdomen
• Findings such as a thyroid nodule, jaundice, hepatic
enlargement, and cushingoid features may point to
secondary causes of osteoporosis
• An imaging technique that measures areal BMD
• The gold standard in measuring the lumbar spine
(L1-4) and femoral neck, total hip, or forearm BMD.
• The spine, which has a greater cancellous bone
content and a larger surface area, is the best site for
monitoring response to treatment because of its
greater rate of change in BMD
• T-score - This number shows the amount of bone
compared with a young adult of the same gender with
peak bone mass.
• Z-score - This number reflects the amount of bone you
have compared with other people in the same age
group and of the same size and gender.
• Both of them is expressed as SD numbers
According to the WHO
• Quantitative Computed Tomography (CT) :
Can be used as an alternative to DXA, however, its not
recommended due to the exposure hazards associated with.Q
• Quantitative Ultrasound:
- Can be used if DXA is not available.
- Lower risk associated compared to CT.
SO FAR ,YOU HAVE
• 1) Risk Factors.
• 2) BMD
• 3) What’s Next..?
• Fracture Risk Assessment for 10 years (FRAX® score).
• The FRAX® models have been developed from studying
population-based cohorts from Europe, North America, Asia
Fracture Risk Assessment for 10 years
• The FRAX®algorithm is available online at
• Screening criteria vary because of gaps in evidence and
differences in the way guidelines are formulated (i.e.,
evidence-based versus expert opinion).
Evidence-based: The U.S. Preventive Services Task Force (USPSTF)
• Screening DEXA in all women 65 years and older.
• AS well as in women 60 to 64 years of age who
have increased fracture risk.
• Insufficient evidence to recommend for or against
screening in postmenopausal women younger
than 60 years.
Expert opinion :The National Osteoporosis Foundation (NOF)
o Women age 65 and older and men age 70 and older, regardless of clinical risk factors .
o Younger postmenopausal women and men age 50 to 69 about whom you have concern
based on their clinical risk factor profile.
o Women in the menopausal transition if there is a specific risk factor associated with
increased fracture risk such as low body weight, prior low-trauma fracture or high risk
o Adults who have a fracture after age 50.
Interventions used for
prevention and treatment
I. Non-Pharmacologic & health advice for all :
Other lifestyle modifications
II. Pharmacological management :
Anti-resorptive (Biphosphonates, Strontium ranelate ,Raloxifen,Calcitonin)
Anabolic (Calcium , Vit.D, Teriparatide , …….
Interventions used for
prevention and treatment
Non-Pharmacologic & health advice
for all :
1. Diet :
Recommended : at least 1,200 mg per day for elderly people.
Supplements should be added if the dietary intake is not
Advice to use rich calcium diet like : milk , yogurt , solid
Use supplementation most of the time is required to complete
the recommended intake (Ca Co3 or citrate ).
Calcium carbonate 1.25 g (500 mg calcium)
Vitamin D :
Chief dietary sources of vitamin D :
Vitamin D-fortified milk (400 IU per quart) .
Cereals (40 to 50 IU per serving), egg yolks, salt-water
fish and liver.
Some calcium supplements and most multivitamin
tablets also contain vitamin D.
Individuals older than age 65 should aim to take 10
micrograms (400 IU) daily.
Encourage sun exposure of 20-30min twice weekly if
2)REGULAR EXERCISE :
Regular weight-bearing and muscle-strengthening exercise to
reduce the risk of falls and fractures
Improve agility, strength, posture and balance, which may reduce
the risk of falls. In addition, modestly increase bone density.
NOF strongly endorses lifelong physical activity at all ages .
Weight-bearing exercise (in which bones and muscles work
against gravity as the feet and legs bear the body’s weight)
includes walking, jogging, Tai-Chi, stair climbing, dancing and
Other life-style modifications
FALL PREVENTION :
Checking and correcting vision and hearing, evaluating any
neurological problems, reviewing prescription medications
for side effects that may affect balance and providing a
checklist for improving safety at home.
Wearing undergarments with hip pad protectors may protect
an individual from injuring the hip in the event of a fall.
Hip protectors may be considered for patients who have
significant risk factors for falling or for patients who have
previously fractured a hip.
For Prevention :
• Patients with osteopenia should be considered for pharmacological intervention based upon
• The risk factors that are best validated include advanced age, prior fragility fracture, parental
history of hip fracture, glucocorticoid use, excess alcohol intake, rheumatoid arthritis, and
current cigarette smoking.
• Patients with the highest probability of fracture are most likely to benefit from drug therapy.
• Bisphosphonates or Raloxifene as first-line choices (Grade 2B).
Who to treat???
Postmenopausal women and men age 50 and older
presenting with the following should be
considered for treatment:
A hip or vertebral (clinical or morphometric) fracture .
T-score ≤ -2.5 at the femoral neck or spine after
appropriate evaluation to exclude secondary causes .
Low bone mass (T-score between -1.0 and -2.5 at the
femoral neck or spine) with risk factors (Prevention)
10-year probability of a hip fracture ≥ 3% or a 10-year
probability of a major osteoporosis-related fracture ≥
20% based on the patient country-adapted WHO.
• Bisphosphonates :
(Alendronate, Alendronate plus D, Ibandronate,
Risedronate, Risedronate with 500 mg of calcium
carbonate and Zoledronic acid)
• Hormonal :
Calcitonin, Estrogens (Estrogen and/or hormone
therapy), (raloxifene) and Parathyroid hormone
I. Patient experiences problems or side effects with
II. Patient shows inadequate response to therapy .
III. A secondary cause of osteoporosis is identified.
• Maxine A. Papadakis, Stephen J. McPhee, Eds. Michael W. Rabow, Associate
Ed.Current Medical Diagnosis & Treatment 2013.
• National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of
Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2010.
• The National Institute for Health and Clinical Excellence (NICE) guidelines on the
prevention of fragility fractures in postmenopausal women with osteoporosis [NICE,
2010b; NICE, 2011a; NICE, 2011b]
• AuthorsHillel N Rosen, MDMarc K Drezner, MD Uptodate .Osteoprosis management
and prevention .
• Franklin D. Shuler, MD, PhD; Jacob Conjeski, MD; DavidKendall, MA; Jonathon
Salava, MD Understanding the Burden of Osteoporosis and Use of the World Health Organization
- Up to date .com
Decalcification and softening of the bone in adult.
• Caused mainly by: vitamin D deficiency
**Vitamin D is required for the absorption of calcium from the intestine and calcium is
responsible for mineralization of bone
Caused mainly by:
Vitamin D deficiency.
Dietary calcium deficiency.
Inhibitors of mineralization
Disorders of bone matrix
• Decreased availability of vitamin D
• Insufficient sunlight exposure
• Nutritional deficiency of vitamin D Malabsorption; aging,
excess wheat bran, bariatric surgery,
pancreatic enzyme deficiency
• Liver disease
• Chronic kidney disease
• Kidney transplantation
• Medications: Anti epileptics (Phenytoin, carbamazepine,
or barbiturate therapy)
• Initially asymptomatic
• Eventually, bone pain, simulating fibromyalgia
• Painful proximal muscle weakness (especially pelvic girdle) due to
• Pathologic fractures with little or no trauma
• Vitamin D deficiency has been associated with a possible increased
– Multiple sclerosis
– Rheumatoid arthritis
– Diabetes mellitus – Hypertension –Psoriasis
• Blood work
• Decreased serum calcium or phosphorus
• Decreased serum 25-hydroxyvitamin D
• Elevated alkaline phosphatase
• Show loose’rs transformation zone –
• ribbons of decalcification in bone
• Vitamin D and Calcium