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Osteoporosis And Fragility Factors

Dr Mahesh Kulkarni

Fragility fractures are defined as fractures resulting from a fall from a standing height or less, or presenting in the absence of obvious trauma.
Fragility fractures affect up to one-half of women and one-third of men over age fifty, and are often associated with low bone density (Osteoporosis)Such fractures occur most commonly in the hip, spine, and wrist.
Osteoporosis is defined as a reduction in the strength of bone that leads to an increased risk of fractures. Loss of bone tissue is associated with deterioration in skeletal microarchitecture.
Clinical trials have demonstrated that treatment of patients with fragility fractures can reduce the risk of future fractures by up to 50%. Thus, it is important that these patients not only receive treatment for the presenting fracture, but also for prevention of future fractures.
Osteoporosis represents a major public health problem because of its association with low-energy trauma or fragility fractures. Hip fracture has been recognized as the most serious consequence of osteoporosis because of its complications, which include chronic pain, disability, diminished quality of life, and premature death.
Causes, incidence, and risk factors :-
Researchers estimate that about 1 out of 5 American women over the age of 50 have osteoporosis. About half of all women over the age of 50 will have a fracture of the hip(Fig.1), wrist (Fig.2), or vertebra (bones of the spine) (Fig.3).
Osteoporosis occurs when the body fails to form enough new bone, when too much old bone is reabsorbed by the body, or both. Calcium and phosphate are two minerals that are essential for normal bone formation. Throughout youth, your body uses these minerals to produce bones. If you do not get enough calcium, or if your body does not absorb enough calcium from the diet, bone production and bone tissues may suffer.
As you age, calcium and phosphate may be reabsorbed back into the body from the bones, which makes the bone tissue weaker. This can result in brittle, fragile bones that are more prone to fractures, even without injury.
Usually, the loss occurs gradually over years. Many times, a person will have a fracture before becoming aware that the disease is present. By the time a fracture occurs, the disease is in its advanced stages and damage is severe.
The leading causes of osteoporosis are a drop in estrogen in women at the time of menopause and a drop in testosterone in men. Women over age 50 and men over age 70 have a higher risk for osteoporosis..

Primary osteoporosis may be divided into
1) Senile osteoporosis and
2) Post-menopausal osteoporosis.
It is said that osteoporosis is a geriatric disease that begins in childhood.

People reach their peak bone mass at about age 28 or 29. From thereafter all patients undergo a gradual decrease in their bone mass. If this decrease is extremely rapid, patients may reach the zone of skeletal failure before dying. They may sustain multiple fractures. Particularly they suffer fractures of the hip, spine and wrist.
These fractures are very common in the elderly population. Senile osteoporosis is a gradual loss of bone secondary to osteoblast senescence.
The remodeling rate is normal. Senile osteoporosis occurs in all patients in all cultures throughout all periods of history. This may be contrasted with post-menopausal osteoporosis which is a rapid decrease of skeletal mass which occurs to some women around menopause. Some women are exquisitely sensitive to estrogen withdrawal.
Estrogen withdrawal releases cytokines which stimulate osteoclastic bone turnover. The increased turnover results in a more rapid incremental bone loss.
Secondary osteoporosis is a pattern of generalized bone loss that occurs in patients who are not yet pre-menopausal or not in the old age group. Generalized bone loss in a middle age person is generally referred to as secondary osteoporosis and is usually related to a specific problem.
The most common causes are steroid therapy or amenorrhea.
Steroid therapy may be seen in patients on long term steroids for organ transplants or autoimmune disorders.
Approximately 30% of patients on long-term steroids will have vertebral crush fractures.
Amenorrhea is another cause of secondary osteoporosis. Young women with eating disorders may develop severe osteoporosis. Similarly, women who have had their ovaries removed may develop osteoporosis as well.
The histopathologic features of senile or postmenopausal osteoporosis are not distinctive except for decreased cortical thickness and decreased cancellous bone volume.


Symptoms & signs:-
 There are no symptoms in the early stages of the disease. Symptoms occurring late in the disease include:
Tests
Bone mineral density testing (specifically a densitometry or DEXA scan) measures how much bone you have.
In severe cases, a spine or hip x-ray may show fracture or collapse of the spinal bones. However, simple x-rays of bones are not very accurate in predicting whether someone is likely to have osteoporosis.
You may need other blood and urine tests if your osteoporosis is thought to be due to a medical condition, rather than simply the usual bone loss seen with older age.

Treatment
The goals of osteoporosis treatment are to: