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.

• Other causes include
• Being confined to a bed
• Chronic rheumatoid arthritis, chronic kidney disease, eating disorders
• Hyperparathyroidism
• Vitamin D deficiency
• While women, especially those with a family history of osteoporosis, have a greater than average risk of developing osteoporosis.
• Other risk factors include:
• Drinking a large amount of alcohol
• Family history of osteoporosis
• History of hormone treatment for prostate cancer or breast cancer
• Low body weight
• Smoking
• Too little calcium in the diet

Symptoms & signs:-

There are no symptoms in the early stages of the disease. Symptoms occurring late in the disease include:

• Bone pain or tenderness
• Fractures with little or no trauma
• Loss of height (as much as 6 inches) over time
• Low back pain due to fractures of the spinal bones
• Neck pain due to fractures of the spinal bones
• Stooped posture or kyphosis, also called a "dowager's hump"

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:

• Control pain from the disease
• Slow down or stop bone loss
• Prevent bone fractures with medicines that strengthen bone
• Minimize the risk of falls that might cause fractures
• There are several different treatments for osteoporosis, including lifestyle changes and a variety of medications.

EXERCISE:-

Regular exercise can reduce the likelihood of bone fractures in people with osteoporosis.

DIET:-

Get at least 1,200 milligrams per day of Calcium and 800 - 1,000 international units of Vitamin D3.

Vitamin D helps your body absorb calcium. Your doctor may recommend a supplement to give you the calcium and vitamin D you need.

Follow a diet that provides the proper amount of calcium, vitamin D, and protein. While this will not completely stop bone loss, it will guarantee that a supply of the materials the body uses to form and maintain bones is available.

High-calcium foods include:

• Cheese
• Ice cream
• Leafy green vegetables, such as spinach and collard greens
• Low-fat milk
• Fish
• Tofu
• Yogurt

STOP UNHEALTHY HABITS

Quit smoking, if you smoke. Also limit alcohol intake.

Too much alcohol can damage your bones, as well as put you at risk for falling and breaking a bone.

PREVENT FALLS

It is critical to prevent falls. Avoid sedating medications and remove household hazards to reduce the risk of fractures. Make sure your vision is good. Other ways to prevent falling include:

• Avoiding walking alone on wet floors.
• Using stick or support while walking.
• Using bars in the bathtub, when needed
• Wearing well-fitting shoes
• Medications are used to strengthen bones when:
• Osteoporosis has been diagnosed by a bone density study.
• Osteopenia(thin bones, but not osteoporosis) has been diagnosed by a bone density study, if a bone fracture has occurred.

Drugs used for treatment of osteoporosis

1) BISPHOSPHONATES

2) CALCITONIN

3) HORMONE REPLACEMENT THERAPY

4) PARATHYROID HORMONE

5) RALOXIFENE

SURGERY FOR FRAGILITY FRACTURES:-

Initiating interventions soon after a fragility fracture occurs may significantly reduce the incidence and severity of subsequent fractures.

There are different methods of surgical management of fragility (Osteoporotic) fractures.

MONITORING

Your response to treatment can be monitored with a series of bone mineral

Fig.1 :- Hip Fracture (# neck of femur )

Operation for Hip Fracture

Fig.2:- Wrist Fracture ( Colle's # )

Operative management of Wrist fracture

Fig.3 :- Spine Fracture (#Vertebral body)