A 58-year-old postmenopausal woman presented with a left wrist fracture following a fall. Her medical history included asthma treated with corticosteroids, gastric ulcer, and a previous wrist fracture. Examination found a displaced, swollen wrist with no neurovascular compromise. X-ray revealed a Colles' fracture. Risk factors for osteoporosis from her history included advanced age, menopause, corticosteroid use, smoking, and lack of exercise. Further workup was needed to confirm the diagnosis and guide management, which may include bisphosphonates, parathyroid hormone, or calcium and vitamin D supplementation to prevent future fractures.

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!