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Osteoporosis 733.00

synonyms:

Osteoporosis ICD-9

  • 733.00 (osteoporosis unspecified)

Osteoporosis Etiology / Epidemiology / Natural History

  • Peak bone mass occurs at 24-34 years old. 60-70% achieved during adolescence.
  • Bone loss accelerates to 2-3% per year during menopause and for the first 8 years postmenopause. 0.5%/year after that.
  • Lifetime hip fx risk for person >50y/o=14% women, 3% men. (Brostrom M, OKU-9).
  • Vertebral body fx risk = 28% for women, 12% for men. (Brostrom M, OKU-9)
  • Wrist fx risk = 13% for women, 2% for men. (Brostrom M, OKU-9)
  • Risk Factors for Fracture: female, elderly, caucasion, prior fragility fx, glucocorticoids, anticonvulsants, benzodiazepines, antidepressants, diabetes, hyperparathyroidism, hyperthyroidism, inflammatory arthritis, hypercortisolism, neuromuscular disorder, eating disorder, family history of fx, low BMI, smoking, proton pump inhibitors (Prevacid, Nexium, Prilosec, Protonix, Aciphex) and histamine-2 receptor antagonists, or H2RAs, (Zantac, Tagamet).

Osteoporosis Associated Fractures

  • Distal radius fracture
  • Proximal humerus fracture
  • Vertebral compression fracture
  • Femoral neck fracture
  • Intertrochanteric femur fracture
  • Subtrochanteric femur fracture

Osteoporosis Clinical Evaluation

  • Assess dietary calcium, phosporus and vitamin D consumption.
  • Document tobacco, cafffine and alcohol use.
  • Assess menstrual history.
  • Document height, weight, bony/ligamentous deformities (dorsal kyphosis, loss of height).

Osteoporosis Xray / Diagnositc Tests

  • Bone densiometry best assesses bone mineral density measurement (BMD) and fracture risk. 5.3% absolute fracture risk for 70y/o with BMD<-2 (Blake GM, J Clin Densiom 2002;5:109).
  • Osteopenia: 1-2.5 standard deviations below mean
  • Osteoporosis: >2.5 standard deviations below mean
  • BMD screening recommendations (www.iscd.org): fragility fracture, men with risk factors, women >65y/o, postmenopausal women, women with fracture risks (family history, weight loss, benzodiazepines, anticonvulsants).
  • Serum calcium (total and free), phosphorous, magnesium, alkaline phosphatase, osteocalcin.
  • Urine/serum N-telopeptides
  • Initial endocroine labs:  24-hr urine for sodium, calcium and creatine.  Serum PTH and vitamin D

Osteoporosis Screening Indicatios

  • Women >65
  • Men 70
  • Age >50 with risk factors:
    -prior fragility facture
    -lupron use
    -corticosteriod use (>7.5mg/day prednisone or equilvalent for > 3months)
    -smoking
    -BMI < 21 for women
    -Parent/sibling histor of hip fracture
    -History of falls in past 12 months

Osteoporosis Classification / Treatment

  • In any patient with a fragility fracture consider ordering a bone mineral density test and forwarding the rests to their PCP.
  • Well balanced diet, exercise, adequate sunlight exposure, no smoking, hip protectors.
  • Calcium, Vitamin Dsupplementation.
  • Active anti-osteoporotic medications should be started following fragility hip fractures (Gardner MJ, JBJS 2005;87:3).
  • Bisphosphates: alendronate 5-10mg PO QD; risedronate 5mg PO QD; ibandronate 2.5mg PO QD
  • Nasal calcitonin and raloxifene
  • Teriparatide (anabolic agent)
  • Key Points for Patients:
    -Fractures may be related to osteoporosis.
    -By having a fragility fracture, patients have a higher risk of hip fracture.
    -Preventive treatment is effective and safe.

Osteoporosis Associated Injuries / Differential Diagnosis

  • Secondary causes of osteoporosis (Cushing's syndrome, hypogonadism)

Osteoporosis Complications

  • Compression fracture
  • Distal radius fracture
  • Femoral neck fracture
  • Intertrochanteric femur fracture
  • Subtrochanteric femur fracture

Osteoporosis Follow-up Care

  • 20% of patients with a fragility fracture will sustained a second fragility fracture within 1 year (Reginster JY, Bone 2006;38(2sup1):S4
  • 16% of osteoporotic women with vertebral fractures with new vertebral fractures within 2 years. Teriparatide (20-40 ug SQ QD) and Raloxifene (60-120mg PO QD) decrease new vertebral fracture risks by @70% and @50% respectively. (Bouxsein ML, JBJS 2009;91A:1329). Also should be taking Calcium 500-1000mg QD and Vitamin D 400-1200 IU QD.

Osteoporosis Review References

 

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