This document discusses the diagnosis and assessment of osteoporosis. It defines osteoporosis as a systemic skeletal disease characterized by low bone mass and deterioration of bone tissue, leading to bone fragility and susceptibility to fractures. It describes who is at risk and the different types of osteoporosis. Physical exams and various imaging techniques can be used to diagnose osteoporosis such as dual-energy x-ray absorptiometry (DXA) scans, quantitative ultrasound, CT scans, and plain radiography. Factors like BMD T-scores, clinical risk factors, and markers of bone turnover help assess fracture risk in patients.

1. DIAGNOSIS OF
OSTEOPOROSIS
DR NITIN KAUSHIK
J.R. ORTHOPAEDICS

2. Definition
A systemic skeletal
disease characterized by
low bone mass and micro
architectural deterioration
of bone tissue leading to
bone fragility and
susceptibility to fracture

3. Who Gets Osteoporosis?
Immobilization
Hypogonadal states
Endocrine disorders
Malnutrition, parenteral nutrition and malabsorption
rheumatologic disorders
Renal insufficiency
Hematologic disorders
Several inherited disorders

4. Osteoporosis
 Mechanisms causing osteoporosis
 Imbalance between rate of resorption and
formation
 Failure to complete stages of remodeling
 Types of osteoporosis
 Type I
 Type II
 Secondary

5. Osteoporosis - Types
 Postmenopausal osteoporosis (type I)
 Caused by lack of estrogen
 Causes PTH to overstimulate osteoclast
 Age-associated osteoporosis (type II)
 Bone loss due to increased bone turnover
 Malabsorption
 Mineral and vitamin deficiency

6. Classification
 Primary
 Postmenopausal
 Bone loss – 2-3% per year of total bone mass
 Most common fx: vertebral, distal forearm
 Age related – 3rd decade of life starts slow decline in
bone mass at rate of 0.5-1% per year
 Most common types of fx: hip and radius
 F>M
 Secondary

7. Secondary Osteoporosis
Disease states
 Acromegaly  Multiple myeloma
 Addison’s disease  Multiple sclerosis
 Amyloidosis  Rheumatoid arthritis
 Anorexia  Sarcoidosis
 COPD  Severe liver dz, esp.
 Hemochromatosis PBC
 Hyperparathyroidism  Thalessemia
 Lymphoma and  Thyrotoxicosis
leukemia
 Malabsorption states

8. Secondary Osteoporosis
Drugs
 Aluminum
 Anticonvulsants
 Excessive thyroxine
 Depo Provera (decreased bone mass
reversible after stopping medication)
 Glucocorticoids
 GnRH agonists
 Heparin
 Lithium

9. Diagnosing Osteoporosis
 Outcome of interest: Fracture Risk!
 Outcome measured (surrogate): BMD
 Key: Older women at higher risk of fracture than
younger women with SAME BMD!
 Other factors: risk of falling, bone fragility not all
related to BMD

10. Prevalence of osteoporosis
Osteopenia Osteoporosis
Female 37-50% 13-18%
Age > 50 year
Male 28-47% 3-6%
Age > 50 year

11. Incidence of osteoporotic Fx

12. Incidence of osteoporotic Fx

13. Diagnosis of Osteoporosis
 Physical examination
 Measurement of bone mineral content
• Dual X-ray absorptiometry (DXA)
• Ultrasonic measurement of bone
• CT scan
• Radiography

14. Physical examination
Osteoporosis Vertebral fracture
 Height loss Arm span-height
 Body weight difference
 Kyphosis Wall- occiput
 Humped back distance
 Tooth loss Rib-pelvis distance
 Skinfold
thickness
 Grip strength

15. Physical examination

16. Physical examination
No single maneuver is sufficient to rule in or
rule out osteoporosis or vertebral fracture
without further testing

17. Diagnosing Osteoporosis
 Laboratory Data
 Limited value in diagnosis
 Markers of bone turnover (telopeptide) more useful in
monitoring effects of treatment than in diagnosis
 Helpful to exclude secondary causes
 Hyperthyroidism
 Hyperparathyroidism
 Estrogen or testosterone deficiency
 Malignancy
 Multiple myeloma
 Calcium/Vitamin D deficiency

18. Work-up
Screen for secondary causes
 Serum calcium, phosphorus, alk phos
 PTH if calcium is high (hyperparathyroidism)
 25-hydroxyvitamin D if low ca,
low phos and high alk. phos (osteomalacia)
 Thyroid function tests (thyrotoxicosis)
 SPEP, UPEP (multiple myeloma)
 24-hour urinary calcium (hyper or hypo calciuria)
 Serum testosterone (hypogonadism)

19. Methods to evaluate for osteoporosis
 Quantitative Ultrasonography
 Quantitative computed tomography
 Dual Energy X-ray Absorptiometry (DEXA)
 ?”gold standard”
 Measurements vary by site
 Heel and forearm: easy but less reliable (outcome of
interest is fracture of vertebra or hip!)
 Hip site: best correlation with future risk hip fracture
 Vertebral spine: predict vertebral fractures; risk of
falsely HIGH scores if underlying OA/osteophytes

20. Dual X-ray absorptiometry
2-dimensional study
BMD = Amount of mineral
Area
Accuracy at hip > 90%
Low radiation exposure
Error in
Osteomalacia
Osteoarthritis
Previous fracture

21. How to interpret the BMD
 T score: standard deviation of the BMD from the
average sex matched 35-year-old
 Z score: less used; standard deviation score compared
to age matched control
 For every 1 decrease in T score, double risk of fracture
 1 SD decrease in BMD = 14 year increase in age for
predicting hip fracture risk
 Regardless of BMD, patients with prior osteoporotic
fracture have up to 5 times risk of future fracture!

22. Dual X-ray absorptiometry
BMD compare with T score
young adult female
Normal < 1 SD below >/= -1
Low bone mass ( Osteopenia ) 1-2.5 SD below < -1
> -2.5
Osteoporosis >/= 2.5 SD below </= -2.5
Severe osteoporosis >/= 2.5 SD below
PLUS Fracture

23. Dual X-ray absorptiometry
WHO criteria - Hip
BMD
Normal
Low bone mass
(Osteopenia)
Osteoporosis
Severe osteoporosis

24. Osteoporosis Can Be Assessed by
DXA
Relative Risk of Fracture DXA-assessed content is a
per SD Decrease in BMD
proven effective method for
3 assessing osteoporosis
2.5 related fracture risk.
Relative Risk
2 Population surveys and
Forearm
1.5 Hip research studies demonstrate
1
Spine a decrease in bone density
0.5 measured by DXA predicts
0 fracture at specific sites.
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25. Ultrasonic measurement
Broad-band ultrasound
attenuation
No radiation exposure
Cannot be used for diagnosis
Preferred use in assessment
of fracture risk

26. The calcaneus is the most common skeletal site
for quantitative ultrasound assessment
because
-It has a high percentage of trabecular bone
that is replaced more often than cortical
bone, providing early evidence of metabolic
change.
-Also, the calcaneus is fairly flat and
parallel, reducing repositioning errors.

27. The McCue CUBA: Ultrasonometry
Technology That Can Assess Osteoporosis

28. Heel BUA is Significantly Lower in
Subjects With Future Hip Fracture.
60
BUA (dB/sq MHz) 50
40
30
20
10
0
Fracture No Fracture
Subjects who developed hip fracture showed significantly (p<0.001) lower
heel BUA results.

29. CT scan
True volumetric study
Quantitative Computed
Tomography (QCT) utilizes CT
technology to detect low bone
mass and monitors the effects of
therapy in patients undergoing
treatment.
It is a fast, non-invasive exam
that detects low bone mass
earlier and more accurately than
other bone density exams

30. QCT in a 62-year-old female patient

31.  The trabecular BMD is indicated as the most
important parameter, and interpreted using the
Felsenberg classification, based on the
following cut-off values:
Normal BMD > 120 mg/cc
Osteopenia < 120 mg/cc
Osteoporosis < 80 mg/cc
Very high fracture risk < 50 mg/cc

32. Advantages over DXA:
 Ability to separate cortical and trabecular bone
 Provides true volumetric density in units of mg/cc
 No errors due to spinal degenerative changes or
aortic calcification

33. Clinicians and researchers favor DXA because
-scanners are readily available and relatively
inexpensive.
-The radiation dose is negligible
-The T-score scale, defined by the WHO specifically for
DXA, provides a standardized classification.

34. Plain radiography
Low sensitivity
High availability
Subclinical vertebral fracture is a
strong risk factor for subsequent
fractures at new vertebral site and
other sites

35. The main radiographic features of generalized
osteoporosis are cortical thinning and increased
radiolucency

36. Singh Index
 The Singh index describes the trabecular
patterns in the bone at the top of the thighbone
(femur).
 X-rays are graded 1 through 6 according to
the disappearance of the normal trabecular
pattern.
 Studies have shown a link between a Singh
index of less than 3 and fractures of the hip,
wrist, and spine.

37. ASSESSMENT OF
FRACTURE RISK

38. Assessment of fracture risk
 DXA and quantitative ultrasound
 Clinical risk factors
 Markers of bone turnover
Bone formation
Bone resorption

39. Assessment of fracture risk
 DXA
Risk of fracture = 1.5-3.0 for each SD
decrease in BMD
Low sensitivity ( comparable to BP in
predicting stroke )
Screening is not recommended
 Quantitative ultrasound
Risk of fracture = 1.5-2.0 for each SD
decrease in BMD

40. Assessment of fracture risk
Markers of bone turnover
Bone formation markers Bone resorption markers
Alkaline phosphatase Hydroxyproline
Bone isoenzyme AP Pyridinium crosslinks &
Osteocalcin associated peptides
Procollagen
propeptides of type I
collagen

41. Assessment of fracture risk
Markers of bone turnover
 Associated with osteoporotic fracture
independent of bone density
 2-Fold increase in fracture risk
 ? Combined approach with BMD to
increased sensitivity

42. Assessment of fracture risk
Clinical risk factors for fracture
 Low bone mass
 History or falls
 Impaired cognition ( plus medication adverse effect )
 Low physical function
 Presence of environmental hazards
 Long hip axis length
 Chronic glucocorticoid use
 Existing fracture
 Chronic use of seizure medications
 Renal, hepatic, thyroid, parathyroid, malabsorptive disorder, vitamin D
deficiency, MM and local neoplasia to be ruled out
National Osteoporosis Foundation 1998

43. Assessment of fracture risk
Predictors of low bone mass
 Female
 Advanced age
 Gonadal hormone deficiency ( estrogen or testosterone )
 White race
 Low body weight & BMI
 Family history of osteoporosis
 Low calcium intake
 Smoking / excessive alcohol intake
 Low level of physical acitivity
 Chronic glucocorticoid use
 History of fracture
National Osteoporosis Foundation 1998

44. When to Measure BMD in
Postmenopausal Women
 All women 65 years and older
 Postmenopausal women <65 years of age:
 Ifresult might influence decisions about
intervention
 One or more risk factors
 History of fracture

45. When Measurement of BMD Is Not
Appropriate
 Healthy premenopausal women
 Healthy children and adolescents
 Women initiating ET/HT for menopausal
symptom relief (other osteoporosis therapies
should not be initiated without BMD
measurement)

46. THANK YOU