Global Statistics

All countries
343,270,696
Confirmed
Updated on January 21, 2022 5:35 am
All countries
274,213,020
Recovered
Updated on January 21, 2022 5:35 am
All countries
5,593,457
Deaths
Updated on January 21, 2022 5:35 am

Global Statistics

All countries
343,270,696
Confirmed
Updated on January 21, 2022 5:35 am
All countries
274,213,020
Recovered
Updated on January 21, 2022 5:35 am
All countries
5,593,457
Deaths
Updated on January 21, 2022 5:35 am

Osteoporosis

Practice Essentials

Osteoporosis, in which low bone mass and micro-structural deterioration of bone tissue lead to increased bone fragility, is the most common metabolic bone disease in the United States.
Osteoporosis can result in devastating physical, psychosocial, and economic consequences. Still, it is often overlooked and undertreated, in large part because it is clinically silent; there are no symptoms before a fracture occurs. (See the image below.)

Osteoporosis of the spine. Observe the considerabl

Osteoporosis of the spine. Observe the considerable reduction in overall vertebral bone density and note the lateral wedge fracture of L2.

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See Menopause: Changes and Challenges, a Critical Images slideshow, to help identify comorbidities and diseases in the postmenopausal population.

Signs and symptoms

Osteoporosis does not become clinically apparent until a fracture occurs and so is sometimes referred to as the “silent disease.” Two-thirds of vertebral fractures are painless, although patients may complain of the resulting stooped posture and height loss. Typical findings in patients with painful vertebral fractures may include the following:

The episode of acute pain may follow a fall or minor trauma.

Pain is localized to a specific, identifiable, vertebral level in the midthoracic to lower thoracic or upper lumbar spine.

The pain is described variably as sharp, nagging, or dull; movement may exacerbate pain; in some cases, pain radiates to the abdomen.

Pain is often accompanied by paravertebral muscle spasms exacerbated by activity and decreased by lying supine.

Patients often remain motionless in bed because of fear of exacerbating the pain.

Acute pain usually resolves after 4-6 weeks; in the setting of multiple fractures with severe kyphosis, the pain may become chronic.

Patients who have sustained a hip fracture may experience the following:

Pain in the groin, posterior buttock, anterior thigh, medial thigh, and/or medial knee during weight-bearing or attempted weight-bearing of the involved extremity

Diminished hip range of motion (ROM), particularly internal rotation and flexion

External rotation of the involved hip while in the resting position

On physical examination, patients with vertebral compression fractures may demonstrate the following:

With acute vertebral fractures, point tenderness over the involved vertebra

Thoracic kyphosis with an exaggerated cervical lordosis (dowager’s hump)

Subsequent loss of lumbar lordosis

A decrease in the height of 2-3 cm after each vertebral compression fracture and progressive kyphosis

Patients with hip fractures may demonstrate the following:

Limited ROM with end-range pain on a FABER (flexion, abduction, and external rotation) hip joint test

Decreased weight-bearing on the fractured side or an antalgic gait pattern

Patients with Colles fractures may have the following:

Pain on movement of the wrist

Dinner fork (bayonet) deformity

Patients with pubic and sacral fractures may have the following:

Marked pain with ambulation

Tenderness to palpation, percussion, or both

With sacral fractures, pain with physical examination techniques used to assess the sacroiliac joint (eg, FABER, Gaenslen, or squish test)

Balance difficulties may be evident, especially in patients with an altered center of gravity from severe kyphosis.
Patients may have difficulty performing tandem gait and performing single-limb stance.

See the Presentation for more detail.

Diagnosis

Baseline laboratory studies include the following:

Complete blood count: May reveal anemia

Serum chemistry levels: Usually normal in persons with primary osteoporosis

Liver function tests

Thyroid-stimulating hormone level: Thyroid dysfunction has been associated with osteoporosis

25-Hydroxyvitamin D level: Vitamin D insufficiency can predispose to osteoporosis

Serum protein electrophoresis: Multiple myeloma may be associated with osteoporosis

24-hour urine calcium/creatinine: Hypercalciuria may be associated with osteoporosis; further investigation with measurement of intact parathyroid hormone and urine pH may be indicated; hypocalciuria may indicate malabsorption, which should be further evaluated with a serum vitamin D measurement and consideration of testing for malabsorption syndromes such as celiac sprue

Testosterone (total and/or free) and luteinizing hormone/follicle-stimulating hormone: Male hypogonadism is associated with osteoporosis

Bone mineral density (BMD) measurement is recommended in the following patients
:

Women age 65 years and older and men age 70 years and older, regardless of clinical risk factors

Postmenopausal women and men above age 50–69, younger postmenopausal women and women in menopausal transition based on risk factor profile

Postmenopausal women and men age 50 and older who have had an adult-age fracture, to diagnose and determine the degree of osteoporosis

Adults with a condition (eg, rheumatoid arthritis) or taking medication (eg, glucocorticoids in a daily dose ≥5 mg prednisone or equivalent for ≥3 months) associated with low bone mass or bone loss

Dual-energy x-ray absorptiometry (DXA) is currently the criterion standard for the evaluation of BMD.
Peripheral DXA is used to measure BMD at the wrist; it may be most useful in identifying patients at very low fracture risk who require no further workup.

DXA provides the patient’s T-score, which is the BMD value compared with that of control subjects who are at their peak BMD.
World Health Organization (WHO) criteria define a normal T-score value as within 1 standard deviation (SD) of the mean BMD value in a healthy young adult. Values lying farther from the mean are stratified as follows
:

T-score of –1 to –2.5 SD indicates osteopenia

T-score of less than –2.5 SD indicates osteoporosis

T-score of less than –2.5 SD with fragility fracture(s) indicates severe osteoporosis

DXA also provides the patient’s Z-score, which reflects a value compared with that of persons matched for age and sex. Z-scores adjusted for ethnicity or race should be used in the following patients:

Premenopausal women

Men younger than 50 years

Children

Z-score values of –2.0 SD or lower are defined as “below the expected range for age” and those above –2.0 SD as “within the expected range for age.” The diagnosis of osteoporosis in these groups should not be based on densitometric criteria alone.

The National Osteoporosis Foundation (NOF) recommends vertebral imaging for the following patients
:

All women age 70 and older and all men age 80 and older whose BMD T-score at the spine, total hip, or femoral neck is –1.0 or lower

All women age 65 to 69 and all men age 70-79 whose BMD T-score at the spine, total hip, or femoral neck is –1.5 or lower

Vertebral imaging is also recommended for postmenopausal women and men age 50 and older with the following specific risk factors:

Low-trauma fractures

Height loss of 1.5 inches (4 cm) or more since peak height at age 20

Height loss of 0.8 inches (2 cm) or more since a previously documented height measurement

Recent or ongoing long-term glucocorticoid treatment

If bone density testing is not available, vertebral imaging may be considered based on age alone.

Other plain radiography features and recommendations are as follows:

Obtain radiographs of the affected area in symptomatic patients.

Lateral spine radiography can be performed in asymptomatic patients in whom a vertebral fracture is suspected; a scoliosis series is useful for detecting occult vertebral fractures.

Radiographic findings can suggest the presence of osteopenia or bone loss but cannot be used to diagnose osteoporosis.

Radiographs may also show other conditions, such as osteoarthritis, disk disease, or spondylolisthesis.

See Workup for more detail.

Management

Lifestyle modification for the prevention of osteoporotic fractures includes the following
:

Increasing weight-bearing and muscle-strengthening exercise to improve agility, strength, posture, and balance, which may reduce the risk of falls

Ensuring optimum calcium and vitamin D intake as an adjunct to active anti-fracture therapy and balanced diet

Tobacco cessation 

Limiting alcohol consumption 

Removing potential risk factors to avoid falls

Pharmacologic therapy

The NOF recommends reserving pharmacologic therapy for postmenopausal women and men aged 50 years or older who present with the following
:

Fragility fracture: a hip or vertebral fracture (vertebral fractures may be clinical or morphometric (ie, identified on a radiograph alone)

T-score of –2.5 or less at the femoral neck, total hip, spine, or 33% of radius after appropriate evaluation to exclude secondary causes

Low bone mass (T-score of –1.0 to –2.5 at the femoral neck or spine) and a 10-year probability of a hip fracture of 3% or greater or a 10-year probability of a major osteoporosis-related fracture of 20% or greater, based on the US-adapted WHO algorithm for calculating fracture risk (
FRAX)

Guidelines from the American Association of Clinical Endocrinologists/American College of Endocrinology include the following recommendations for choosing drugs to treat postmenopausal osteoporosis
:

First-line agents for most high fracture risk patients: alendronate, risedronate, zoledronic acid, ibandronate, raloxifene (latter two not recommended for the reduction of nonvertebral or hip fracture risk)

First-line agents for spine-specific indications in select patients: ibandronate and raloxifene

First-line agents for high fracture risk patients unable to use oral therapy: zoledronic acid, denosumab

First-line agents for very high fracture risk, including those with multiple fractures: teriparatide, abaloparatide for up to two years, romosozumab for up to one year (should not be considered in women at high risk of cardiovascular disease or stroke)

Sequential agents: anabolic agents (eg, abaloparatide, teriparatide, romosozumab) should be followed with a bisphosphonate or denosumab

Guidelines from the American College of Rheumatology for the treatment of glucocorticoid-induced osteoporosis include the following
:

Designation of moderate-to-high risk or low-risk categories for adults ≥40 years of age receiving long term glucocorticoids by fracture risk score (using the
FRAX score)

No tools to estimate absolute fracture risk in children or adults ≤40 years of age. Considered high risk if previously sustained osteoporotic fracture and moderate risk if on glucocorticoid treatment ≥7.5 mg for 6 months and had either hip or spine BMD Z-score less than -3 or 2 or rapidly declining hip or spine BMD ≥ 10% in one year while on glucocorticoid treatment

Strong or conditional recommendations for initiation of treatment in women with non-childbearing potential and men on glucocorticoids with high, moderate, to low fracture risk in order of preference: oral bisphosphonates, IV bisphosphonates, teriparatide, denosumab, and raloxifene

Medical care also includes identifying and treating potentially treatable underlying causes of osteoporosis, such as hyperparathyroidism and hyperthyroidism.

See Treatment and Medication for more detail.

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