4. DEFINITION
Osteoporosis is a clinical disorder that is characterized by an abnormally low
bone mass & defects in bone structure, a combination which causing the
bone to be unusually fragile and at greater than normal risk of fracture in a
person of that age, sex and race. (Apley & Solomon, 10th edition)
Osteoporosis is defined as a skeletal disorder characterised by compromised
bone strength predisposing a person to an increased risk of fracture.
(CPG 2022, 3rd edition)
5. NORMAL BONE VS OSTEOPOROSIS
OSTEOCLAST
DIFFERENTIATING
FACTOR (RANKL)
● PTH
● Glucocorticoids
● Pro-inflammatory
cytokines
8. PRIMARY CAUSES SECONDARY CAUSES
● Postmenopausal osteoporosis –
due to accelerated bone loss
related to estrogen deficiency
● Age-related osteoporosis –
occurs in men and women
● Idiopathic osteoporosis – rarely
occurs
Endocrine
● Cushing’s syndrome
● Hypogonadism
● Thyrotoxicosis
● Primary hyperparathyroidism
● Type 2 diabetes mellitus
Drugs
● Glucocorticoids
● Heparin
● Anticonvulsants (e.g. phenytoin)
● Immunosuppressants
● Thiazolidinediones
● Treatment in oncology (e.g. aromatase inhibitors, androgen deprivation
therapy)
Chronic diseases
● Chronic kidney disease
● Chronic liver disease
● Chronic inflammatory polyarthropathies (e.g. RA / SLE)
● Neurological diseases (e.g. stroke, Parkinson’s disease)
Nutrition
● Nutritional deficiency (e.g. anorexia nervosa)
● Malabsorption syndrome
● Inflammatory bowel disease
● Post-gastrectomy/gastric bypass surgical procedures
Others : Multiple myeloma and malignancy / Osteogenesis imperfecta
CAUSES OF OSTEOPOROSIS
Androgen & estrogen -stimulate bone growth &
preserve bone mass
Glucocorticoids - suppressed bone formation
Thyroxine - increase bone turnover
Growth hormone - influence bone remodelling
Calcitonin - reduce osteoclast activity
9.
10. CLINICAL PRESENTATION
Mostly are asymptomatic, and diagnosis is made only after a
fracture.
Common clinical presentations :
● Increasing dorsal kyphosis (Dowager’s hump)
● A low-trauma fracture, i.e. - After a fall from standing height or less
● Fractures (distal radius (colles’ fracture) →vertebrae→hip)
○ Hip
○ Spine
○ Forearm
○ Humerus
○ Ribs
○ Tibia (excluding ankle)
○ Pelvis
○ Other femoral fractures
● Historical height loss of >4cm (>1.5 inches)
● Acute back pain following seemingly innocuous activities, e.g.
bending, lifting objects, coughing or sneezing
11. DIAGNOSIS OF OSTEOPOROSIS
TREATMENT OF
OSTEOPOROSIS
SHOULD BE
INITIATED
GOLD STANDARD FOR DIAGNOSIS OF OSTEOPOROSIS
bone mineral density (BMD) measurement
12. INDICATIONS FOR BMD TESTING
● All adults (≥18 years old) with a fragility fracture
● All adults (≥18 years old) with a disease, condition or taking medications
associated with low bone mass or bone loss
● Anyone being considered for pharmacological therapy for osteoporosis
● Those being treated for osteoporosis and to monitor treatment effect
● Anyone not receiving therapy but with evidence of bone loss that would lead to
treatment
● All women who are aged ≥65 years and in men aged ≥70 years
● Postmenopausal women <65 years old, women during the menopausal transition,
women discontinuing estrogen, and in men <70 years old with clinical risk
factors for fracture
13. Bone mineral density (BMD) measurement
● BMD measurement via dual-energy x-ray
absorptiometry (DXA) at the femoral neck, total hip
or lumbar spine
○ lumbar spine (L1-L4, posteroanterior)
○ hip (to include the femoral neck or total hip)
● Forearm BMD (1/3rd radius of the non-dominant
forearm)
○ when the hip and/or spine cannot be measured
or interpreted,
○ Hyperparathyroidism patient
○ very obese patients (over the weight limit for the
DXA table).
● BMD measurement is also used for determining
fracture risk and treatment decisions
● BMD is reported as a T-score or Z-score
○ Both units are standard deviation (SD).
○ T score - mean for young adults (20 - 29 y/o)
○ Z score - for premenopausal women, men <50
years old and children.
Z score low -> tro other causes such as
hyperparathyroidism, malignant disease/
hypocorticosm
14. INVESTIGATIONS
BLOOD INVESTIGATIONS
● Full blood count (FBC)
● Erythrocyte sedimentation rate (ESR)
● Bone profile (serum) – Calcium, phosphate, albumin
● Renal function test - tro CKD (renal osteodystrophy)
● Liver function tests - ALP level
● 25-hydroxy vitamin D [25(OH)D] (preferable)
To rule out secondary causes
● Thyroid function test
● Intact parathyroid hormone (i-PTH)
● Serum protein electrophoresis and free kappa and
lambda light chains
● Morning serum testosterone, follicle-stimulating
hormone (FSH), luteinizing hormone (LH)
● 24-hour urine calcium and creatinine (TRO
hyperparathyroidism)
IMAGING
● Plain x-rays of the lateral
thoraco-lumbar spine (if indicated
– to look for asymptomatic vertebral
fractures)
○ not recommended as
radiological osteopenia is
apparent in plain X-rays only
after >30% of bone loss has
occurred.
● Quantitative ultrasound
○ Not recommended
● Dual energy X-ray absorptiometry
(DXA) - gold standard
15. X - RAY FINDINGS OF OSTEOPOROSIS
● Evidence of fracture
● Kyphosis of the spine
● Increased radiolucency of bones.
(radiological osteopenia- d/t low bone
density)
● Loss of trabecular definition -> singh index
● Thinning of cortices
Lateral chest radiograph of a 71-year-old man with a grade 2
osteoporotic vertebral fracture at T11 with 35% height loss
measured by dividing the height of the posterior border of the
vertebral body by the anterior height (white lines).
Compression fracture
17. SINGH INDEX
classification system for bone density of the femoral neck based on the visibility of the
trabecular types that can be seen in the femoral neck.
18. ● grade 1: only thin principal compression trabeculae visible
● grade 2: principle compression trabeculae present, other trabeculae nearly resorbed
● grade 3: principle tensile trabeculae thinned and breakage in continuity present
● grade 4: principal tensile trabeculae thinned without loss of continuity
● grade 5: principle tensile and compression trabeculae readily visible with prominence of Ward triangle
● grade 6: all trabeculae visible and of normal thickness
Grade 3 and below indicate definite osteoporosis.
As osteoporosis progresses these trabeculae get thinner and eventually disappear.
Grade 6
Grade 4
Grade 5
Grade 3
20. Screening for osteoporosis is recommended for individuals
with :
1. Prior low-trauma fractures
2. Those with clinical risk factors
3. Secondary osteoporosis
4. Height loss and falls risk
5. All postmenopausal women ≥50 years old.
Tool risk assessment:
1. Fracture Risk Assessment Tool
2. Malaysia Osteoporosis Screening Tool
3. Osteoporosis Self Assessment Tool for Asians
SCREENING FOR OSTEOPOROSIS
21. Fracture Risk Assessment Tool
1. Estimates the 10-year probability
of hip fracture and major
osteoporotic fracture (hip, clinical
spine, proximal humerus, or
forearm) for untreated patients
between ages 40 to 90 years
using clinical risk factors.
22. Malaysian Osteoporosis Screening
Tool
1. Calculates the risk of low BMD
among women based on age,
years since menopause, body
mass index (BMI) and hip
circumference.
2. It performed well among women
3. Cannot be used in men.
Osteoporosis Self Assessment
Tool for Asians
1. A simple clinical screening tool
that is based on age and weight
developed for postmenopausal
Asian women.
2. Women in the
moderate-to-high-risk categories
with additional risk factors for
osteoporosis should be
recommended for DXA.
23.
24. PREVENTION OF OSTEOPOROSIS
Nutrition
Calcium & Vitamin D intake
● Important for peak bone mass attainment
and osteoporosis prevention in adults
and postmenopausal women
● Vitamin D supplements are available as
ergocalciferol (vitamin D2) and
cholecalciferol (vitamin D3)
● Suggestion for adults who are vitamin D
deficiency be treated with 50,000 IU of
vitamin D2 or vitamin D3 once a week for
eight weeks
25. Nutrition
Body Weight
● Low body mass index
● Being overweight or obese
Caffeine Intake
● Caffeine increases faecal and urinary
calcium excretion and may induce a
negative calcium balance
● High caffeine intake (>330 mg
caffeine/day) associated with increased
risk of fragility fracture.
● Patients that regularly consume
caffeinated drinks should be advised to
increase their calcium intake accordingly.
Smoking
● Increases osteoporotic fracture risk
Alcohol Consumption
● Excessive alcohol intake (>2 units
daily) should be avoided as it has been
associated with increased rates of any
fracture and osteoporotic fracture in
both men and women
26. Exercise
Regular exercise
● Regular physical activity, in particular
weight-bearing exercise is encouraged.
● Helps in all age groups to maximise peak bone
mass, decrease age-related bone loss, maintain
muscle strength and balance.
● Individual’s health status should be taken into
consideration when recommending an exercise
programme.
27. Prevention of fall
All older persons ≥65 years old should be
screened at least once a year for:
● Falls
● Frequency of falling
● Difficulties in gait balance
Older adults who are screened positive
should receive a thorough assessment of
falls risk factors and given interventions to
reduce falls risk.
28. Prevention of fall
Assessment & Intervention for Falls Prevention
Evaluate lower limb muscle
strength, gait, and balance
Poor gait, strength and balance
● Refer for physical therapy
● Engagement in exercise programmes that involve balance,
functional exercise and resistance training
Identify medications that
increase fall risk
Medication(s) likely to increase fall risk
● Optimise medications by stopping, switching or reducing dosage
Ask about potential home
hazards (e.g. slippery
bathroom floor, loose rugs)
Home hazards likely to increase fall risk
● Refer to an occupational therapist to evaluate home safety
assessment ± modification
Measure positional blood
pressure (supine and
standing blood pressure
measurement)
Orthostatic hypotension observed
● Review medications
● Encourage adequate hydration
● Consider use of compression stockings, abdominal binders or
physical manoeuvres
29. Assessment & Intervention for Falls Prevention
Check visual acuity Visual impairment observed
● Refer ophthalmologist/optometrist
● Avoid wearing multifocal glasses when walking, particularly stairs
Assess feet and footwear Feet or footwear issues identified
● Appropriate treatment for foot problem identified -Advise wearing
well fitted shoes indoors and outdoors
Assess vitamin D intake Vitamin D deficiency observed or likely
● Recommended daily vitamin D (800-1000 IU) supplement for
individuals with proven vitamin D deficiency
Previous history of falls OR
fear of falling
Provide falls education and information to all patients
● Regular follow up to ensure adherence to interventions
Prevention of fall
30. MANAGEMENT OF OSTEOPOROSIS
Who should get treatment?
Post menopausal women and men age > 50
with:
● Hip or vertebral fracture
● Low bone mass (T-score between -1.0
and -2.5 at the femoral neck or lumbar
spine
● With a FRAX fracture probability of >3%
at 10 years for hip or 20% at 10 years
for major osteoporosis-related fracture
AIM : To reduce the risk of future fracture
● Individuals with osteoporosis should have
optimisation of calcium and vitamin D
intake and lifestyle intervention together
with pharmacological therapy
● Low-risk individual: menopausal hormone
replacement/selective estrogen receptor
modulators
● High-risk individuals: antiresorptives.
● Very high-risk individuals: anabolic agent if
available and other alternatives.
31. Menopausal Hormone Therapy
● Offered to symptomatic women <60 years
old and within 10 years of menopause
helps prevent and treat postmenopausal
osteoporosis
● Available as estrogen therapy (ET) &
combined estrogen progestogen therapy
(EPT)
● Increase BMD at all skeletal sites and
reduce fragility fracture risk, and reduce
bone turnover.
Tibolone
● A synthetic hormone with estrogenic,
progestogenic, and androgenic properties
● Indicated for the relief of menopausal
symptoms and the prevention of
osteoporosis
● significantly increased lumbar and hip
BMD, and greater absolute reduction
among women with prior vertebral fracture
● Women who are one year past their last
period may be offered Tibolone.
● Not advised in older postmenopausal
women due to increased risk of stroke.
● Annual Monitoring
Selective Estrogen Receptor Modulator
● Synthetic non-steroidal molecules that
bind to estrogen receptors throughout the
body.
● They act as an estrogen agonist or
antagonist depending on the target organ.
● Raloxifene (RLX) is a second-generation
SERM.
32. Biphosphonate
● Potent inhibitors of bone resorption.
● Alendronate, Risedronate, Ibandronate,
Zoledronic acid
● Oral bisphosphonates are not
recommended for patients with an eGFR
<30 ml/min (chronic kidney disease stage
4-5)
● It is recommended to review the efficacy
of bisphosphonate treatment after 3-5
years.
● Common Complication of
Bisphosphonate therapy :
- Atypical femoral fractures
- Osteonecrosis of the Jaw
- Gastrointestinal : Nausea, Vomiting
● Women at high risk (high fracture risk
score FRAX, major osteoporotic fracture
can cont. medication up to 10 years
Recombinant PTH1-34
● A potent anabolic agent.
● Indicated for individuals with very high
risk for fractures or osteoporosis not
responding to treatment
● Recommended for up to 24 months
● Subcutaneously administered r-PTH at 20
μg daily for 21 months increases lumbar
spine BMD by up to 8.6% and femoral
neck BMD by 3.5%
● S/e : Dizziness, leg cramps and
hypercalcaemia.
33. Denosumab
● A human monoclonal antibody (IgG) that
inhibits the formation, function, and survival of
osteoclasts by inhibiting RANK ligand, thus
reducing bone resorption.
● If denosumab is stopped, subsequent
treatment with another treatment option
should be initiated due to possible increased
risk of multiple vertebral fractures
● Treatment reassessment may be done after
5-10 years and those who remain at high
fracture risk should either continue
denosumab or be switched to other
osteoporosis therapies
Calcium & Vitamin D
● Vitamin D supplementation (at least
800 IU/day) in combination with
calcium (1200 mg/day elemental
calcium) is recommended for fracture
and fall prevention in people above 50
years of age who are at risk of
fractures
● The available activated vitamin D
analogues are calcitriol and
alfacalcidol.
Romosozumab
● An anabolic agent. It is a humanised monoclonal antibody that binds to sclerostin.
● Resulting in an increase in bone formation and BMD.
● RMZ is contraindicated in patients who have had a myocardial infarction or stroke within
the past one year.
35. Introduction
● increasingly common due to aging population (7th - 8th decade)
● women > men
● risk factors include :
1. Osteoporosis
- The association with osteoporosis is so manifest that the incidence of femoral neck
fractures has been used as a measure of age-related osteoporosis in population
studies.
2. Bone-losing or bone-weakening disorders (e.g. osteomalacia)
3. Stroke (disuse)
4. Elderly
- They often have weak muscles and poor balance resulting in an increased tendency
to fall.
5. Female
36. Etiology
(Pathophysiology)
a) healing potential
- femoral neck is intracapsular, bathed in synovial fluid
- lacks periosteal layer
- callus formation limited, which affects healing
(Mechanism)
a) low energy falls in older patients
fracture usually results from a simple fall. however, in very osteoporotic people less force is
required–– perhaps no more than catching a toe in the carpet and twisting the hip into
external rotation. Some patients may have experienced minor symptoms of a preceding
stress fracture of the femoral neck.
b) high energy in young patients
In younger individuals, the usual cause is a fall from a height or a blow sustained in MVA.
These patients often have multiple injuries and in 20 % there is an associated fracture of
the femoral shaft. Occasionally, stress fractures of the femoral neck occur in runners or
military personnel.
38. Blood supply
- major contributor : terminal branch of medial femoral circumflex artery (lateral
epiphyseal artery)
- some contribution to anterior and inferior head : lateral femoral circumflex artery
- some contribution : inferior gluteal artery
- small and insignificant supply : artery of ligamentum teres
Femoral neck is intracapsular. They have a poor capacity for healing because :
1) tearing of the retinacular vessels by injury will deprive the head of its main blood supply
2) intra-articular bone has only a flimsy periosteum and no contact with soft tissues that
could promote callus formation
3) synovial fluid prevents clotting of the fracture haematoma.
43. Clinical Features
(in elderly : history of a fall) :
i) impacted and stress fractures
- slight pain in the groin or pain referred along the medial side of the thigh and
knee
ii) displaced fractures
- pain in the entire hip region
*In older patients, should determine the reason for any fall (eg, syncope, stroke), assess
for additional orthopedic (deformity, function of patient) and internal injuries (loss of
consciousness, vomiting)
(in young adults : road traffic accidents or falls from heights)
- associated with multiple injuries
*A good rule is that young adults with severe injuries , whether they complain of hip pain
or not ; should always be examined for an associated femoral neck fracture.
44. Physical Examination :
impacted and stress fractures
- no obvious clinical deformity
- tender with active/passive hip ROM (limited), muscle spasms
- tender at fracture site
displaced fractures
- leg in external rotation and abduction with shortening
neurovascular examination (sciatic nerve injury)
45. Investigation
1. Hip X-ray
Recommended views :
- APview : with maximal internal rotation and lateral view is best for defining fracture
type
- Full length femur
Optional views
- consider obtaining imaging of uninjured hip to use as template intraop
To look for :
❏ Shenton’s line disruption
❏ Lesser trochanter more prominent
❏ Femur appeared flexion & ext rotated
❏ Bone trabeculae angulated
46. 2. CT
- helpful in determining displacement and degree of comminution in some patients
3. MRI
- helpful to rule out occult fracture
- not helpful in reliably assessing viability of femoral head after fracture
4. Bone scan
- helpful to rule out occult fracture
- not helpful in reliably assessing viability of femoral head after fracture
5. Duplex Scanning
- indication : rule out DVT if delayed presentation to hospital after hip fracture
47. Treatment
Operative
1. ORIF
- Indications : displaced fractures in young patients ( most pt <50 y/o)
2. cannulated screw fixation
- Indications : nondisplaced transcervical #
: displaced transcervical # in young patient
- achieve reduction to limit vascular insult
- reduction must be anatomic, so open if necessary
Garden I & II OR + cannulation screw
Garden III & IV OR + cannulation screw +
sliding screw
48. 3. sliding hip screw
- Indications : basicervical fracture
: vertical fracture pattern in a young patient
-sliding hip screw biomechanically superior to cannulated screws (may not be
clinically superior)
- consider placement of additional cannulated screw above sliding hip screw to prevent rotation
4. hemiarthroplasty
- Indications : debilitated elderly patients
: metabolic bone disease
- cemented hemiarthroplasty
: decreased intraoperative and postoperative fracture rates in elderly insufficiency fractures
: improved short and medium term mobility
49. 5. total hip arthroplasty
- Indications : older active patients
: patients with preexisting hip osteoarthritis
- more predictable pain relief and better functional outcome
than hemiarthroplasty
: Garden III or IV in patient < 85 years
50. Complication
1. Osteonecrosis
- incidence of 10-45%
- increased risk with :
a) patient with displaced #
b) non-anatomical reduction
c) sliding hip screw
- AVN may be painless initially but causes pain (localized to the groin or ipsilateral buttock
region) & limits motion over time
- But may manifest as referred knee pain & increases with weight bearing
- Radiographic assessment using : MRI or bone scan is necessary when AVN is suspected
Changes on plain radiographs do not reliably appear until 6 months after AVN first develops
- Treatment :
❏ young patient : > 50% involvement then treat with FVFG vs THA
❏ older patient : prosthetic replacement (hemiarthroplasty vs THA)
51. 2. Nonunion
● incidence of 5 to 30%
● increased incidence in displaced fractures
● factors determine the risk of nonunion :
- patient age, bone density, fracture displacement, fracture comminution, reduction quality, the
prosthetic device and its position.
- can present with groin, hip or thigh pain that never fully resolves following surgery/ increases
after a period of improvement.
● treatment :
a) valgus intertrochanteric osteotomy
- indicated in patients after femoral neck nonunion
- can be done even in presence of AVN, as long as not severely collapsed
- turns vertical # line into horizontal # line and decreases shear forces across # line
b) free vascularized fibula graft (FVFG)
- indicated in young patients with a viable femoral head
c) arthroplasty
- indicated in older patients or when the femoral head is not viable
- also an option in younger patient with a nonviable femoral head as opposed to FVFG
d) revision ORIF
52. 3. Dislocation
- higher rate of dislocation with THA (~ 10%) ; about 7x higher than hemiarthroplasty
4. Failure rates
- high early failure rates in fixation group, which stabilizes after 2 years
- 2-year follow-up (elderly population >70 years) with displaced femoral neck fractures
46% failure with fixation techniques
8% failure with arthroplasty techniques
- overall failure rates still higher in fixation vs. arthroplasty at 10-year follow-up
5. Loss of independence
- requiring walking aids and assisted living following fracture surgery
- the timed up and go (TUG) test has been identified as a reliable predictor of a patient's need
for post-operative assistive devices
● Normal TUG is <12 seconds in all age groups
● Persistent use of ambulatory aids is predicted if TUG > 26 seconds
- associated factors :
age >80 years
prior walking aid use
current tobacco use
implant placement quality
53. COLLE’S FRACtURE
04
● Defined as transverse fracture of the radius with dorsal displacement of the fragment
● Common of all fracture in older people.
● High incidence related to the onset of the postmenopausal osteoporosis. thus , it usually
involved older woman
54. Mechanism of injury
1. Fall on outstretched hand (FOOSH) most common in elderly (low energy
mechanism)
2. High energy mechanism more common in younger patients
Clinica features
● Wrist pain
● Wrist swelling
● Wrist deformity
● Ecchymosis
● Diffuse
tenderness
● Limited ROM
Special features
● Undisplaced fracture:
pain, swelling, little or
no deformity
● Displaced fracture:
‘dinner fork’ deformity
55. 1. The radius is fractured at the corticocancellous junction, about 2 cm from the wrist
2. Often the ulnar styloid is also fractured.
3. Characteristically, the distal fragment is shifted and tilted both dorsally and towards
the radial side
4. In some cases the fracture is impacted or severely comminuted.
Imaging: X-Ray
56. Management
Undisplaced fracture DIsplaced fracture Comminuted and unstable
fracture
● Dorsal splint is
applied for 1 or 2 days
until swelling resolved.
● The cast is completed
● Usually when the
fracture is stable, the
cast can usually be
removed after 4
weeks to allow
mobilization
● Reduced under anesthesia
Hold
● Dorsal plaster slab is applied
extending from below the elbow to
the metacarpal neck
Rehabilitation
● Arm kept elevated for 1-2 days
● Shoulder and fingers exercise ASAP
Monitoring
● If the fingers become swollen,
cyanosed or painful, split bandage.
● X-ray at day 10 (displacement check)
● If plaster immobilization
alone cannot hold the
fracture + Percutaneous
K-wiring (removed after 5
weeks)
For very unstable fracture,
external fixator is the best
option.
● Proximal pin placed
through the radius
● Distal pin placed through
the shaft of 2nd
metacarpal
Internal fixation with metal
plated applied to the front of
distal radius
57. Complication
Circulatory impairment Circulation in the finger must be checked
Nerve injury Median nerve may be compressed by swelling
Malunion Is common. Because of reduction not complete or
displacement within the plaster
Associated radioulnar and
carpal injury
Ligament strain around the wrist
Tendon rupture Rupture of the extensor pollicis longus
Joint stiffness Stiffness of elbow wrist, finger
Complex regional pain
syndrome
Broad term describing excessive and prolonged pain
and inflammation that can occur following an injury
Reference
Apley and Solomon’s Concise System of Orthopaedics and Trauma; Injuries of the forearm and wrist;
Orthobullets; Distal radius fracture
https://www.ncbi.nlm.nih.gov/books/NBK553071/
https://www.physio-pedia.com/Colles_Fracture
https://www.ninds.nih.gov/health-information/disorders/complex-regional-pain-syndrome
60. ● occur secondary to an axial/compressive load
with resultant biomechanical failure of the bone
resulting in a fracture
● It compromise the anterior column of spine >
compromise to the anterior half of VB & anterior
longitudinal ligament > Wedge shape deformity
● It does not involve the posterior half of VB &
posterior ligamentous complex
● Compression # usually considered stable & do not
require surgical instrumentation
Introduction
61.
62. Etiology :
● Osteoporosis
● High energy mechanism (Fall from
height , MVA)
Epidemiology :
● 25% of woman at 5o years of age
and older have at least 1 VCF
● 40%-50% of patients over age 80
have sustained a VCF
● 60-75% occur at thoracolumbar
junction
● 30% occur at L2 to L5 region
Clinical features:
● Sudden onset of back pain
● Increase pain during
standing/walking , on palpation
● Decrease pain when lying down
● Decrease spinal mobility (d/t pain)
Characteristics :
● Wedge-shape
● Cortical break in upper anterior wall
● Horizontal sclerotic band of trabecular
impaction
● Fractures of superior endplate
● Posterior cortex of body intact
63. Fall/trauma,the spinal column will rotate around a center of axis
Also associated with axial force d/t flexion/extension of spine
Axial force > the force tolerable by vertebral body
Pathophysiology
Compression Fracture
64. Risk Factors
Modifiable
● Alcohol consumption
● Smoking
● Estrogen deficiency
● Early menopause
● Impaired eyesight
● Low body weight
● Dietary Calcium deficiency
● Vit D deficiency
Non-Modifiable
● Advanced age
● Female
● Dementia
● H/o fracture in adulthood
65. Investigation
● Plain radiograph :
○ Evidence of Vertebral disruption
○ Post-traumatic kyphotic
angulation :assessment of
fracture progression
Vertebral disruption :
● Loss of vertebral height
● Disruption in alignment along anterior and
posterior vertebral body lines
● Facet dislocation
● Increase in interpedicular and interspinous
distance (>7 mm)
Kyphotic angulation :
Angle between the superior end
plate one level above and the inferior
end plate one level below the injured
segment.
66. CT Scan
● Plain film suggest injury
● Detect instability of an
anterior wedge
compression fracture, and
occult bony injuries.
● Ideal for imaging complex
fractures and determining
the degree of vertebral
67. MRI
● Neurological deficit
● cord compression and
ligamentous disruption
● evaluating the age of the
VCF
● If contraindicated for MRI
→CT myelography
69. NON-SURGICAL
● Short period of bed rest followed
by gradual mobilization with
external orthoses
● Analgesic/Narcotic
● Physical therapy/rehabilitation
SURGICAL
● Indications :
○ patients with intractable
back pain failing conservative
therapy
○ evidence of impending or
existing neurologic deficit
○ spinal deformity is extremely
severe
● Type of surgery :
○ Vertebroplasty
○ Kyphoplasty
70.
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