A 62-year old woman was brought to the emergency

department due to pain in her arm after she tripped in

CLINICAL DATABASEthe kitchen landing onto her right forearm.

X-ray showed a fracture at the distal end of the

radius as well as moderate reduction of radio
density.
Considering that she is postmenopausal woman
and because of the mildness of the fall, with the
finding of reduced radio density of the radius,
osteoporosis was suspected.
She had menopause 7 years ago and claimed to
have been healthy with no maintenance
medication.
She eats a healthy diet but she does not exercise
nor take any vitamin/mineral supplement.
She smokes a pack of cigarette a day but drinks
alcoholic beverages only occasionally.
The fracture was reduced and cast was applied. She
was instructed to follow up after 2 weeks for further
work-up.
DEXA (dual energy x-ray absorptiometry) scan as well
as other test were done and the results were
consistent with severe osteoporosis.
 OSTEOPOROSIS
means porous
bones, causes bones
to become weak and
brittle.
It is a reduction in the
strength of bone that
leads to an increased
risk of fractures.
 involves a gradual
loss of calcium, as Decreased
well as structural estrogen levels
changes, causing
the bones to Chief clinical
become thinner, manifestations are:
more fragile and Vertebral fracture
more likely to Hip fracture
break.
Normal vs. osteoporotic
 Causation of
osteoporosis
Alterations of the levels of various factors
(hormones, cytokines, nutritional) result in
an increase of osteoclastic activity over
osteoblastic activity. In post-menopausal
osteoporosis, loss of estrogen is critical.

Resorption of bone with loss of matrix
(mainly collagen type 1, other proteins e.g.
osteocalcin) with the preservation of the
ratio of matrix: mineral (hydroxyapatite).

Fragility of bones, often resulting in
fractures (hip fractures are among
the most serious).
 PRIMARY TYPE 1 (Postmenopausal osteoporosis)

condition commonly occurs in women

after the menopause. More than 95%
in women and about 80% in men.

A major cause of osteoporosis is a lack

of estrogen, particularly the rapid
decrease that occurs at menopause.

Most men over 50 have higher

estrogen levels than postmenopausal
women, but these levels also decline
with aging, and low estrogen levels are
associated with osteoporosis in both
men and women. Estrogen deficiency
increases bone breakdown and results
in rapid bone loss.
 In men, low levels of male
sex hormones also
contribute to osteoporosis.
Bone loss is even greater if
calcium intake or vitamin
D levels are low.

Low vitamin D levels result

in calcium deficiency and
increased activity of the
parathyroid glands
(secreting parathyroid
hormone), which can also
stimulate bone
breakdown. For unknown
reasons, bone production
also decreases.
 PRIMARY TYPE 2 ( Senile / age-
associated osteoporosis
occurs in both sexes post 75 years,
although more prevalent in women (ratio
2:1, female: male )

closely related to vitamin D and calcium

deficiencies.

Disorders that may cause secondary

osteoporosis are
chronic kidney disease
hormonal disorders (especially Cushing
disease, hyperparathyroidism,
hyperthyroidism, hypogonadism, high
levels of prolactin, and diabetes mellitus).
 IDIOPATHIC OSTEOPOROSIS

both adults and

teenagers can be
affected by this type of
osteoporosis.

when children develop

this, they can reverse it
through proper lifestyle
changes and certain
medications.

the cause is unknown.

Bone formation
Bone resorption
 The role of estrogen in bone
metabolism
Estrogen is a group of sex
steroids produced by the
ovaries of females and
testes of men.
Estradiol is the main
estrogen hormone
involved in bone mineral
density for both genders.
Levels of estradiol can
vary depending on your
stage of life.
 Estrogen inhibits
osteoclasts activity in
bone and stimulates
osteoblasts activity.

It also inhibits the

osteoclasts
recruitment, so the
body has fewer
osteoclasts available to
break the bones down.
 DEXA (Dual energy x-
ray absorptiometry)

Bone density scanning,

also called dual-energy x-
ray absorptiometry (DXA)
or bonedensitometry
an enhanced form ofx-ray
technology that is used to
measure bone loss.
standard for measuring
bone
mineraldensity(BMD).
Plan of treatment /
intervention
Medications:
Adequate calcium intake

Bisphosphonates Life stage group Estimated

Alendronate Adequate Daily
Calcium Intake,
Risendronate mg/d
Ibandronate)
Young children (1-3 500
Estrogen Replacement years)
Therapy Older children (4-8 800
years)
Start appropriate doses of
calcium citrate and vitaminAdolescent and young 1300
D adults
(9-18 years)

Medications made from

Men and women (19- 1000
natural hormones
50 years)
(Calcitonin)
Men and women
Source: (51
adapted from1200
the standing
SERMs (Selective Estrogen and older) on the scientific evaluation of
committee
Receptor Modulators)
dietary reference intakes. Food and
Tamoxifen Nutrition board. Institute of Medicine.
raloxifene Washington, DC, 1997, National Academy
Management of osteoporotic

fracture
ORIF with pins and
plates

Hemiathroplasties

Total Arthroplasties

Kyphoplasty and
vertebroplasty
 Thank you!
Resources:
Harpers Illustrated
Biochemistry
Harrisons
Principles of
Internal Medicine