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OSTEOPOROSIS

Introduction

Bone mass increases in youth and peaks for most people in their early 20s. With increasing age, however, bone loss surpasses bone growth. A variety of risk factors can predispose a patient to the weakening and eventually fragile bones characteristic of osteoporosis. In the presence of osteoporosis, fracture risk is high, and an initial fracture is a major risk factor for another. Weakened bones lead to instability and an increased risk of falling. In patients with distal radius fractures, 34% of women and 17% of men have osteoporosis. When normal or low-energy force is the mechanism, the osteoporotic injury is called a “fragility fracture.” Hand surgeons are often the first to see a patient with osteoporosis, after a fragility fracture. Therefore, hand surgeons should be alert to osteoporosis and refer appropriately.  

Pathophysiology

  • Collagen type 1 fibrils wind together and link with non-collagenous proteins, which help prevent shearing. Hydroxyapatite crystals within the collagen structure add strength.
  • In osteoporotic bone, linkage of collagen fibrils and non-collagenous proteins is reduced, weakening the structure.
  • Larger hydroxyapatite crystals make bones more brittle and prone to fracture.

Related Anatomy

  • Osteoporosis-related fractures are most common in the hip, wrist, or spine.
  • The most common cause of hip fractures in the elderly is falling, which can lead to disability and increased risk of death within the first year of injury.

Incidence and Related Conditions

  • Incidence is expected to greatly increase with the aging of worldwide populations.
  • Related conditions include celiac disease, inflammatory bowel disease (IBD), cancer, lupus, and rheumatoid arthritis (RA)
  • Patients at highest risk are white and Asian women—particularly those in pre- (aged <45 y) or post-menopause (~30% of women).
  • Other risk factors: family history, small body frame and underweight, hormone levels (hyperthyroid, parathyroid, adrenals; hypotestosterone, estrogen), gastrointestinal surgery that affects nutrient absorption, low calcium intake, lifestyle choices (eg, alcohol abuse, tobacco use, lack of exercise)

Differential Diagnosis

  • Bone marrow diseases (eg, multiple myeloma)
  • Connective tissue diseases (eg, Ehlers-Danlos syndrome, osteogenesis imperfecta)
  • Endocrinopathies (eg, Type I diabetes mellitus)
  • Paget disease
  • Parathyroid adenoma
ICD-10 Codes

  • OSTEOPOROSIS

    Diagnostic Guide Name

    OSTEOPOROSIS

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    OSTEOPOROSIS, AGE RELATED, WITHOUT FRACTUREM81.0   

    Instructions (ICD 10 CM 2020, U.S. Version)

    USE ADDITIONAL CODE TO IDENTIFY: MAJOR OSSEOUS DEFECT, IF APPLICABLE (M89.7-), PERSONAL HISTORY OF (HEALED) OSTEOPOROSIS FRACTURE, IF APPLICABLE (Z87.310)

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Basic Science Photos and Related Diagrams
Histology of Normal Bone
Basic Science Pics
  • Histology of normal bone: A = Long bone (femur); B = Harvested section; C = Medullary cavity; D = Osteons; E = Concentric lamellae; F = Circumferential lamellae; G = Central canal with artery (a), vein(v), nerve(n); H = Periosteum; I = Lacunae with osteocytes
    Histology of normal bone: A = Long bone (femur); B = Harvested section; C = Medullary cavity; D = Osteons; E = Concentric lamellae; F = Circumferential lamellae; G = Central canal with artery (a), vein(v), nerve(n); H = Periosteum; I = Lacunae with osteocytes
Symptoms
None in early stages
Back pain (fractured or collapsed vertebrae) with or without stooped posture
Loss of height
Vulnerability to bone fracture
Typical History

Early osteoporosis will not be evident on physical examination, but a history of low calcium intake, gastrointestinal surgery, alcohol abuse, smoking, and the presence of other risk factors will suggest a work-up for osteoporosis. Patients presenting with advanced osteoporosis likely have not had regular physical examinations because physicians, especially those that practice preventive medicine, are alert for this disorder in those at risk. Advanced osteoporosis will be associated with a history of bone fracture(s), spinal deformity (eg, stooped posture), and perhaps back or neck pain.

Work-up Options
Treatment Options
Conservative
  • Bisphosphonates (most widely prescribed)
  • Denosumab, injection every 6 months
  • Estrogen replacement therapy
  • Raloxifene
  • Teriparatide, daily injection for 2 years
  • Testosterone replacement therapy
  • Vitamin D and calcium therapy
  • Various novel therapies are under study (eg, cathepsin-K inhibitors)
Operative
  • Surgery does not treat osteoporosis, but rather the fractures resulting from the disease.  
Complications
  • Fragility fractures
Outcomes
  • Poor adherence with osteoporosis medications is associated with negative outcomes, including increased fracture risk.
  • Overall adherence is estimated to be 60%.
  • Adherence with bisphosphonates and raloxifene is 55–65%.
  • Some studies have shown that a consistently high level of adherence (>90%) is needed for optimal reduction of fracture risk.
Key Educational Points
  • Only 1–13% of patients with fragility fractures are treated for osteoporosis.
  • New imaging methods such as high-resolution peripheral quantitative CT and micro–MRI are under investigation for better prediction of fracture risk.
  • Inadequate vitamin D is receiving increasing recognition as a contributory factor.
  • Upper-extremity surgeons must address not only fragility fractures but the underlying osteoporosis and associated conditions.
  • Exam Findings: Back pain, Height loss, Spine curvature
  • Bone density scan of hip, spine, or forearm radius (ie, dual-energy X-ray absorptiometry [DEXA])—most accurate method for diagnosing osteoporosis
  • 24-hour urine calcium measurement
  • 25-hydroxyvitamin D test
  • Biochemical marker tests (eg, N-telopeptide of type 1 collagen, C-telopeptide of type 1 collagen)
  • Blood calcium and hormone levels
  • Fracture risk assessment tool (FRAX)
  • Nonspecific imaging: CT scans, MRI, nuclear bone scans, X-rays
References

New Articles

  1. Fojas MC, Southerland LT, Phieffer LS, et al. Compliance to The Joint Commission proposed Core Measure set on osteoporosis-associated fracture: review of different secondary fracture prevention programs in an open medical system from 2010 to 2015. Arch Osteoporos 2017;12:Epub. PMID: 28155141
  2. Curtis EM, Moon RJ, Dennison EM, et al. Recent advances in the pathogenesis and treatment of osteoporosis. Clin Med (Lond) 2015;15(Suppl):6:s92-6. PMID: 26634690

Reviews

  1. Cohen A. Premenopausal Osteoporosis. Endocrinol Metab Clin North Am 2017;46(1):117-33. PMID: 28131128
  2. Bandeira L, Bilezikian JP. Novel therapies for postmenopausal osteoporosis. Endocrinol Metab Clin North Am 2017;46(1):207-219. PMID: 28131134
  3. Aynardi M, Ilyas AM. Pharmacologic management of osteoporosis. J Hand Surg Am 2013;38(3):588-92. PMID: 23312206

Classic

  1. Stevenson JC, Whitehead MI. Postmenopausal osteoporosis. Br Med J (Clin Res Ed) 1982;285(6342):585-8. PMID: 6819027
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