The document provides an overview of metabolic and endocrine bone disorders, particularly focusing on osteoporosis, including its clinical presentation, diagnostic criteria, risk factors, and treatment options. It details how patients present to orthopedic surgeons, the significance of bone density assessments, and various biochemical tests for diagnosis. The treatment section emphasizes medication to reduce fracture risk, lifestyle modifications, and the importance of addressing secondary causes of osteoporosis.

1. Metabolic and endocrine bone
disorders
Osteoporosis

2. Introduction
Patients with metabolic bone disorders usually appear to the
orthopaedic surgeon in one of the following guises:
• A child with bone deformities (rickets)
• An elderly with a fracture of femoral neck or vertebral body
• An elderly patient with bone pain and multiple compression fractures
• A middle-aged person with hypercalcaemia and pseudogout
• Someone with multiple fractures and history of prolonged
corticosteroid treatment

3. X-ray features
 Stress fractures
 Vertebral fractures,
 Cortical thinning
 Loss of trabecular structure
 Ill-defined loss of radiographic density

4. History
 Failure to thrive
 Below-normal growth
 Deformity of the lower limbs
 Back pain
 Generalized muscle weakness

5. Cont’d
 Patient’s sex and age
 Race
 Onset of menopause
 Nutritional background
 Level of physical activity
 Previous illnesses medication and operations
 Onset and duration of symptoms and their relationship to previous
disease

6. cont’d
 Retarded growth
 Malnutrition
 Dietary fads
 Intestinal malabsorption
 Alcohol abuse and cigarette smoking

7. Examination
 Moon face
 Cushingoid build
 Smooth, hairless skin of testicular atrophy
 Physical underdevelopment and bone deformities.
 Thoracic kyphosis

8. X-rays
 Decreased skeletal radiodensity
 Reduction in mineral or skeletal mass
 Presence of obvious fractures
 Small stress fractures

9. Measurement of bone mass
 Dual-energy X-ray absorptiometry (DXA) scan

10. Indications for bone densitometry
 Adults over the age of 50 who have experienced a low
trauma fracture
 All women over the age of 65
 All men over the age of 75
 To assess risk of future fracture
 To assess the degree and progress of bone loss
 To monitor the effect of treatment for osteoporosis.

11. Biochemical tests
 Serum calcium and phosphate concentrations should be
measured in the fasting state
 Raised in osteomalacia and in disorders associated with
high bone turnover

12. Bone biopsy
 Are obtained from the iliac crest
 Examined for histological bone volume, osteoid
formation and relative distribution of formation and
resorption surfaces

13. Osteoporosis

14. Definition
 Abnormally low bone mass
 Defects in bone structure, a combination which renders
the bone unusually fragile

15. Cause
 Predominant bone resorption, decreased bone
formation or a combination of the two

16. Risk factors for osteoporosis
 Age
 Female
 Previous fragility fracture
 Current use or frequent recent use of oral or systemic
glucocorticoids
 Family history of hip fracture
 Low body mass index (BMI) (less than 18.5 kg/m2)
 Smoking
 Alcohol intake of more than 14 units per week for
women and more than 21 units per week for men

17. X-rays
 Loss of trabecular definition,
 Thinning of the cortices
 Insufficiency fractures.
 Compression fractures of the vertebral bodies

18. Postmenopausal Osteoporosis
 It is an exaggerated form of the physiological bone
depletion that normally accompanies ageing and loss of
gonadal activity

19. Clinical features and investigations
 Osteoporosis is asymptomatic unless fractures occur.
 The fractures are classically low trauma
 Fracture of the distal radius (Colles’ fracture) is usually
the first fracture
 Osteoporotic vertebral fractures
 Significant height loss (often exceeding 4 cm) and
thoracic kyphosis
 Height loss and smaller kyphoses are most commonly
due to degenerative change.

20. Cont’d
 Assessment of fracture risk
 The rate of bone turnover is either normal or slightly
increased

21. Prevention
 Medications to reduce fracture risk.
 Primary screening for people who have not sustained
 Women should be advised on lifestyle choices to
maintain healthy bones.

22. Treatment
 The goal is to reduce risk of future fracture.
 Medications recommended for 3–5 years, after which
ongoing treatment should be reconsidered
 Bisphosphonates; taken orally
 Zoledronate can be given once per year intravenously.
 Denosumab subcutaneously injected every 6 months
 Parathyroid hormone Preotact and Teriparatide
 Selective oestrogen receptor modulators (SERMs)

23. Cont’d
 Strontium salt of ranelic acid, given as a sachet of
granules to be dissolved in water and drunk once per
day.
 Operative treatment.
 Analgesic treatment.
 Physiotherapy
 Postural training when symptoms allow.
 Spinal orthoses maybe needed for support and pain
relief
 Vertebral augmentation such as kyphoplasty or

24. Secondary causes of Osteoporosis
 Endocrine; Hypogonadism in either sex
 Treatment with aromatase inhibitors or androgen deprivation
therapy
 Hyperthyroidism
 Hyperparathyroidism
 Hyperprolactinaemia
 Cushing’s disease and Diabetes

25. Cont’d
 Respiratory; Cystic fibrosis and Smoking-related lung disease
 Metabolic; Homocystinuria
 Chronic renal disease
 Gastrointestinal; Coeliac disease, Inflammatory bowel disease,
Chronic liver disease
 Rheumatological; Rheumatoid arthritis and Other inflammatory
arthropathies
 Haematological; Multiple myeloma, Haemoglobinopathies and
Systemic mastocytosis
 Immobility; Neurological injury and Neurological disease