Definitions - Osteopenia: ↓ bone mass; appears as loosened bone on x-ray - Osteomalacia: insufficiency of bone matrix mineralization (↓ quality) - Osteoporosis: loss of total bone mass (↓ quantity); characterized by low bone mass & microarchitectural deterioration of bone T ↑ bone fragility, ↑ risk of fracture with less P DEXA T- score < - 2.5 SD OSTEOPOROSIS (OP) 1. Primary: idiopathic 2. Secondary: caused by identifiable conditions such as: nutritional def, endocrine pathologies (thyroid, parathyroid, KI dis), BM or CT disorders, drug related - m/c metabolic origin ↓ in RISK FACTORS /EPIDEMIOLOGY: - Asymptomatic – first presentation Physical Exam Allopathic therapeutic options: 1) Age: post menopausal, 5x - most ppl at risk of OP completely - lifestyle recommendations, CA & Vit density & quality of bone fracture (hip, wrist, vertebrae m/c) increase risk/decade, idiopathic OP normal clinical exam D, Bispohosphonates, HRT, - general, regional or local - back pain, loss of ht, kyphosis from in pre-menopausal & juvenile = rare - measure height, examine spine, Raloxifene, Calcitriol, Calcitonic, - #1 fracture site – vertebral fracture 2) Gender: females 2x more, 25% Teriparatide Sx: fracture site, proximal muscle fractures, #2 – hip fracture in men - asymptomatic until fracture weakness 3) Race: Caucasians & Asians Primary prevention is ultimate - pain, disability, poor mobility Etiology: increased risk therapeutic goal - abdominal complaints DDX: - extremely common (1 in 4 women 4)Genetics: 80% bone mass - most tx only puts back 5-10% of (compression) - sex hormone deficiency (M/C) > 50years) genetically determined, Vit D & bone over 5 yrs - pulmonary s restrictive LU dz - glucocorticoid XS - 40% lifetime fracture risk in estrogen receptors - reduction of modifiable risk factors - osteomalacia Caucasian women at 50 - back/ soft tissue pain is vital - hyperparathyroidism - 1 in 2 Caucasian women will suffer Causes: Ss: - once bone has been lost it is - osteogenesis imperfecta - estrogen(females)/ testosterone - tenderness @ fracture site impossible to replace it with from osteoporotic fracture risk in (deficiency of osteoclasts) (males) deficiency - bony deformity structurally normal bone their lifetime - multiple myeloma - increased age - kyphosis & loss of ht w/ fractures - glucocorticosteroid use Clinical Risk Categories: - lax ab muscles w/ protuberant ab Lab Tests: 1) Extremely High: prior OP fracture - Cushings, hyperPTH, Fracture threshold: 1o tests to dx 2o causes: 2) Very High: Glucocorticosteroid hyperthyroidism, malabsorption, - BMD below which fracture risk ↑ - Serum Ca2+, serum Phosphate, 3) High: post menopausal w/ >1 of: severe LIV disease, herparin Tx, total ALP/bone ALP, LIV/KI function >65yrs, Hx fracture w/out trauma Immobility, Vit D deficiency tests, CBC, thyroid function tests, Physiological activity of bone: >40yrs, FxHx fracture >50, current Increase bone: calcitriol (active 25-H vit D level (elderly), serum smoker, wt < 127lbs, Frailty vitD), Calcitonin, Estrogen, - balance btwn osteoblastic & testosterone (men) 4) Moderate Risk: post meno, no testosterone, GH, GF, PTH osteoclastic activity 2o tests to dx causes: HRT, no other factors, FxHx OP Decrease bone: PTH, Thyroid - bone turnover = 100% in infants, - PTH levels (w/ ABN Ca2+& P-), Medications: cyclosporine, GnRH tx, hormone, cortisol serum PRO & electrophoresis(w/ 18% in adults per yr anticonvulsants, heparin, tacrolimus, ABN CBC), 24 hr urine Ca & tamoxifen b/f menopause, inhaled 2o Causes: - influenced by calcitonin (from Creatinine & free cortisol, urine GC - lymphoma, leukemia, multiple thyroid gland), PTH (from para- PRO electrophoresis & Bence Conditions w/ association: myeloma, tumor secreting PTH- thyroid gland), 1,25-dihydroxl- Jones PRO, XRAY(past/present - alcoholism, Cushings, gastrectomy, related peptide (or PTH), Addison’s cholecalciferol (vit D, skin), & fracture) hypogonadism, hemochromatosis, disease, amyloidosis, congenital estrogen hyperPTH, IBD, LV dz, multiple porphyria, hemochromatosis, - affected by: extracellular fluids & Testing for Dx & monitoring: myeloma, malabsorption, RA, hemophilia, thalassemia DEXA (Dual Energy Xray mechanical stress premonopausal amenorrhea absorptiometry) Prognosis/Outcomes: - single photon xray absorptiometry, - 70% respond to tx & stabilize CT, QUS - 20-30% w/ hip fracture (femoral neck) institutionalized / die - Men die > hip fracture Definition & Etiology Pathogenesis & Signs & Sx Dx & DDx Tx & Other Prognosis
- Repeat DEXA to monitor Tx
- Continue CS tx OSTEOARTHRITIS (DJD) - Definition: degenerative disease in which degeneration & loss of articular cartilage occur together with new bone formation at the jt surfaces & margins, leading to pain & deformity. 1. Primary: idiopathic 2. Secondary: dt trauma, prior inflammation, arthritis, endocrine pathologies & metabolic disorders (see OP) - Cartilage: is physiologically active so disruptions in biomechanics disruptions in normal synthesis & degradation ↓ in tensile strength and ↓ ability to deform; surface becomes less tolerant to stress cartilage erosion - 2 main functions: 1. Absorbing stress by deforming 2. Provides a smooth, frictionless surface for mvmt in the joint - m/c joint disorder Epidemiology: Sx: Lab Testing Treatment (allopathic): 1) Age: by 40 radiographs show - aching pain in jts (<use, >rest) - generally noncontributory 1. Education / exercise/ wt loss - affects synovial, wt bearing joints; 90% have OA changes to wt bearing - stiffness on waking/ inactivity - normal ESR, CBC, negative ANA, 2. Paracetamol (Tylenol tx) w/ focal areas of cartilage loss & jts, <45 m/c in men, > 55 m/c in absent RF 3. Glucosamine (oral/topical), (<30 min) remodeling of subchondral bone women - Dx of exclusion Topical NSAIDS or capsaicin - pain w/ ROM - knee joint m/c’ly affected 2) Race: knee OA higher in African - Synovial Fluid analysis (WBC, % - jt enlargement, jt buckling 4. COX inhibitors / Opiods (jt - predilection for distal & proximal American women, Hip OA higher in /instability PMN) injections) / NSAIDS Europeans/ Caucasian American ITP joints; zygopopheal (facet) jnts - referred pain away from affected jt 3) Gender: equally affected, pattern of spine; hip - loss of function of jt, flexion Dx Evaluation: Risk Factors (complications)when of jt involvement similar Women contractures - radiography may confirm OA & taking NSAIDS: Etiology: DIPs, PIPs 1st carpometacarpal jts; Ss: assess severity - upper GI complications - 2-6% of popl’n Men hips - crepitus w/ motion - Pain: >rest, <movt/ wt bearing - age > 65ys - Begins asymptomatically in 20-30s 4) Genetics: FxHx of herberden’s - limited / pain w/ motion - Previous trauma/injury / fracture / - Co-morbid med conditions and common by 70 nodes (female side of family), - bony enlargement of affected jts surgery - Use of oral glucocorticoids - 33-90% of ppl > 65 show evidence mutation in type II collagen gene (Herberden’s nodes, Bouchards - P/E: distinguish b/w - Hx of peptic ulcer disease of OA seen with 1o OA nodes) inflammatory & non-inflamm - Hx of upper GI hemorrhage 5) Geography: closer to equator, but - Misalignment / jt deformity condition - Renal complications Sx less severe in warm climates - Raised serum Creatinine levels 6) SES: mech. Stress related to Features: XRAY decrease in jt space d/t - Hypertension Prognosis: occupation/ activity - Bony spur, no ankylosis, decreased articular cartilage (may - CHF - progressive process, leading to subchondral cyst, subchondral see pseudocytes, osteophytes - Use of ACE inhibitors continual loss of articular cartilage, Pathophysiology of OA sclerosis, osteophyte, thinned & - Use of diuretics pain & eventual loss of ROM in - Change in force vectors across jnt fibrillated cartilage DDX: advanced stages w/ full loss of surfaces effects the cartilage of the - Infective arthritis #1 Tx for OA is exercise maintain cartilage joint - RA (chronic inflamm. RF, > am) ROM - ligaments become lax, jt becomes Micro: synovial fluid pushes into - Bursitis, tendonitis, less stable subchondral bone geode - Psoriatic arthritis Recommendations: - jt enlargement & osteophyte Metaplasia: ↑ stress at the - Polymyalgia rhematica - exercise regularly, control wt, eat formation can cause locking of jt capsule insertion osteophyte healthy, know limits, avoid strain on - continual deformity, muscle atrophy formation jts, spread wt over jts, stretch, good & pseudocysts posture, use strong muscles, apply - occasionally know to stop or Cartilage breakdown dt: HEAT, apply cold for flare ups, reverse - repetitive/excessive impulse orthodics, relaxation, positive attitude loading - immobility (↓ nourishment to the jnt) - developmental disorders Definition & Etiology Pathogenesis & Signs & Sx Dx & DDx Tx & Other Prognosis