Case

1. From 373:383
Case scenario

3. 58 years old white woman presents to accident and emergency
department with left wrist pain, swelling, and displacement following a
fall onto outstretched hand at home.
Menstrual history: menopause 50 years’ old
Past history: asthma since childhood (treated with corticosteroids),
gastric ulcer aged 45, right wrist fracture aged 57.
Family history: stroke in sister aged 65, hip fracture in mother aged 78.

4. 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 living).
On examination: wrist displaced, swollen, no open wound No loss
of sensation or vascular compromise.
X-ray: Colles’ fracture of distal radius present. Colles’ fracture
treated conservatively with cast and analgesia

6. OBJECTIVES
1

7.  Differential diagnosis for this case? How to differentiate?
 What underlying condition contributed to this fracture? Key point
from history and examination?
 Age and Sex related differences in bone mass?
 What is bone strength?
 What is RANK, RANKL and OPG pathway?
 Mention pathogenesis of this disease? risk factors?
 What sites of fracture are most common in this condition?
 Further Investigation to support your diagnosis?
 What is the differences between T-score and Z-score?
 Management Plan?

8. Pathologic fractures :(minor trauma ) occur through
areas of weakened bone due to primary malignant
lesions, benign lesions, metastasis, or underlying
metabolic abnormalities as fragility fracture which
result from a minor trauma, most commonly occur at
the hip, spine, or wrist, and indicate that osteoporosis.
Traumatic fracture : (major trauma) occurs when
significant or extreme force is applied to a bone.
caused by a fall or car accident as stress fractures
which are tiny cracks in a bone ,commonly, in the
weight-bearing bones of the lower leg and foot.

9.  Differential diagnosis for this case? How to differentiate?
 What underlying condition contributed to this fracture? Key
point from history and examination?
 Age and Sex related differences in bone mass?
 What is bone strength?
 What is RANK, RANKL and OPG pathway?
 Mention pathogenesis of this disease? risk factors?
 What sites of fracture are most common in this condition?
 Further Investigation to support your diagnosis?
 What is the differences between T-score and Z-score?
 Management Plan?

10. Key points from history and examination?
o 58 years old woman (advanced age >50 years)
o Post menopausal state
o White ethnicity
o Full onto outstretched hand
o Treated with corticosteroids
o History of gastric ulcer ( may be treated with PPI)
o History of fractures
o Smoking 5 cigarettes per day
o Occasionally alcohol
o No exercise inspite of fully mobile and able to complete ADLs
o Wrist displaced
o No loss of sensation o vascular
compromise
o Colles fracture of distal radius
o Family history of fracture

11.  Differential diagnosis for this case? How to differentiate?
 What underlying condition contributed to this fracture? Key point
from history and examination?
 Age and Sex related differences in bone mass?
 What is bone strength?
 What is RANK, RANKL and OPG pathway?
 Mention pathogenesis of this disease? risk factors?
 What sites of fracture are most common in this condition?
 Further Investigation to support your diagnosis?
 What is the differences between T-score and Z-score?
 Management Plan?

12. In young: the body makes new bone faster than it breaks down
old bones, and the bone mass increases.
In mid 30s: reaches the beak bone mass.
After 40: bone remolding continues, but loses slightly more
than gain.
At menopause: when estrogen levels drops, bone loss
increases.
The role of sex hormones: Low estrogen or testosterone as in
late menarche, premature menopause, menopausal state,
testosterone deficiency in males decreases the bone mass.
Bone mass decreases in female more than male

13.  Differential diagnosis for this case? How to differentiate?
 What underlying condition contributed to this fracture? Key point
from history and examination?
 Age and Sex related differences in bone mass?
 What is bone strength?
 What is RANK, RANKL and OPG pathway?
 Mention pathogenesis of this disease? risk factors?
 What sites of fracture are most common in this condition?
 Further Investigation to support your diagnosis?
 What is the differences between T-score and Z-score?
 Management Plan?

14. Bone strength ( density and quality of
bone):
It is determined by bone geometry (size
,shape), cortical thickness, porosity and
trabecular bone morphology.
Bone strength is indirectly estimated by
bone mineral density using Dual energy
X-Ray absorptiometry (DXA).

15.  Differential diagnosis for this case? How to differentiate?
 What underlying condition contributed to this fracture? Key point
from history and examination?
 Age and Sex related differences in bone mass?
 What is bone strength?
 What is RANK, RANKL and OPG pathway?
 Mention pathogenesis of this disease? risk factors?
 What sites of fracture are most common in this condition?
 Further Investigation to support your diagnosis?
 What is the differences between T-score and Z-score?
 Management Plan?

16. RANK ligand:
o It is a protein on the surface of
osteoblast.
o when RANK ligand is attached with
RANK on osteoclast precursor, this
activate osteoclast which actives bone
resorption OPG (osteoprotegenin )
osteoclastgenesis inhibiting factor

17.  Differential diagnosis for this case? How to differentiate?
 What underlying condition contributed to this fracture? Key point
from history and examination?
 Age and Sex related differences in bone mass?
 What is bone strength?
 What is RANK, RANKL and OPG pathway?
 Mention pathogenesis of this disease? risk factors?
 What sites of fracture are most common in this condition?
 Further Investigation to support your diagnosis?
 What is the differences between T-score and Z-score?
 Management Plan?

18. Pathogenesis
Bone mass peaks around the third decade of life and slowly
decrease afterward. Therefore nutrition and physical activity
are important during growth and development .
Physiologically bone remodeling has 4 sequential phases :

19. Activation :
conversion of bone surface
from quiscence to Active form
Reversal :
octeoclast complete the
resorption. produce signals that
initiate bone formation
Resorption :
differentiation of osteoclast
into maturity
Formation:
Mesenchyme cells differentiate
into functional osteoblasts to
make the bone matrix
01
03
02
04
Bone Remodeling :4 phase

20.  Under physiologic conditions bone formation and resorption are in fair balance
a change in this balance may lead to osteoporosis.

21. Risk factors of osteoporosis:

23.  Differential diagnosis for this case? How to differentiate?
 What underlying condition contributed to this fracture? Key point
from history and examination?
 Age and Sex related differences in bone mass?
 What is bone strength?
 What is RANK, RANKL and OPG pathway?
 Mention pathogenesis of this disease? risk factors?
 What sites of fracture are most common in this condition?
 Further Investigation to support your diagnosis?
 What is the differences between T-score and Z-score?
 Management Plan?

24. Fractures caused by osteoporosis
most often occur in the spine.
Spinal fractures — called vertebral
compression fractures and also
affect ribs ,hip and wrist.

26.  Differential diagnosis for this case? How to differentiate?
 What underlying condition contributed to this fracture? Key point
from history and examination?
 Age and Sex related differences in bone mass?
 What is bone strength?
 What is RANK, RANKL and OPG pathway?
 Mention pathogenesis of this disease? risk factors?
 What sites of fracture are most common in this condition?
 Further Investigation to support your diagnosis?
 What is the differences between T-score and Z-score?
 Management Plan?

27. o Laboratory markers: to exclude secondary cause
of osteoporosis .
o Plain radiography: indicated if fracture is
already suspected or if patient have lost more
than 1.5 inch.
o Dual energy x ray( DXA) : Gold standard used
to calculate BMD.
o Quantitative computed tomography (QCT).
o Magnetic resonance imaging (MRI).

29.  Differential diagnosis for this case? How to differentiate?
 What underlying condition contributed to this fracture? Key point
from history and examination?
 Age and Sex related differences in bone mass?
 What is bone strength?
 What is RANK, RANKL and OPG pathway?
 Mention pathogenesis of this disease? risk factors?
 What sites of fracture are most common in this condition?
 Further Investigation to support your diagnosis?
 What is the differences between T-score and Z-score?
 Management Plan?

30. The T-score is a comparison of a person’s bone density with
that of a healthy 30-year-old of the same sex.
The Z-score is a comparison of a person’s bone density with
that of an average person of the same age and sex.
Lower scores (more negative) mean lower bone density:
A T-score of -2.5 or lower qualifies as osteoporosis.
A T-score of -1.0 to -2.5 signifies osteopenia, meaning
below-normal bone density without full .
Z-scores are not used to formally diagnose osteoporosis. Low
Z-scores can sometimes be a clue to look for a cause of
osteoporosis.

32.  Differential diagnosis for this case? How to differentiate?
 What underlying condition contributed to this fracture? Key point
from history and examination?
 Age and Sex related differences in bone mass?
 What is bone strength?
 What is RANK, RANKL and OPG pathway?
 Mention pathogenesis of this disease? risk factors?
 What sites of fracture are most common in this condition?
 Further Investigation to support your diagnosis?
 What is the differences between T-score and Z-score?
 Management Plan?

33. o Bisphosphonates (antiresorptive drugs) slow bone loss.
o Parathyroid hormone analogue ( Teriparatide )
o Calcitonin: helps prevent spine fraction - nasal spray or injection
under skin
o Selective estrogen receptor modulators SERMS , mimic
estrogen's good effects on bones without some of the serious side
effects such as breast cancer
o Densomab: is monoclonal antibody against the receptor activator
of legend ( RANKL )
o Parathyroid hormone analogue ( Teriparatide )helps stimulate
bone formation

34. Prevention :
o Vitamin D intake : 1000 IU daily .
o Exercise , awareness of falls and fall prevention .
o Smoking cessation and avoid alcohol use .
o Calcium intake :1200 mg / day from all sources

36. Team Members:
o Dina Hazem
o Dina Khalid
o Dina Salah
o Dina Ezzat
o Dina Mohamed Elshal
o Dina Mohamed Ashosh
o Roaa Ibrahim
o Ranya Sherif
o Rabab Yahia
o Rehab Mamdouh

37. THANKS!