Background

Decreased mineral density in bones brought on by changed bone morphology is known as osteoporosis, which ultimately predisposes individuals to brittle fractures with low force. Life quality is significantly reduced as a result of osteoporotic fractures, which also raise morbidity, disability, and mortality.

White postmenopausal women will get an osteoporotic-related injury in over 50 percent of cases. About 33 percent of elderly women with hip fractures may regain their independence. The probability of an osteoporotic fracture in white men is 20%, while male hip fracture mortality in the first year is double that of female hip fracture mortality.

Despite having lower rates of osteoporosis than their white counterparts, black men and women nevertheless face the same risk of fracture. The number of bone fractures is predicted to increase as the American population ages.

Epidemiology

Osteoporosis affects more than 200 million people worldwide, and the prevalence rises with advancing age. The impacted population is almost 70 percent of those over 80. Males are less likely to experience it than females. The male and female prevalence varies between 2 percent and 8 percent and 9 percent to 38 percent in the developed world.

Osteoporosis causes about nine million fractures annually throughout the world. An osteoporotic fracture will occur in 1 in 3 females and 1 in 5 males over the age of 50. Compared to persons living at lower latitudes, regions of the world with less vitamin D from sunlight experience a higher incidence of fracture.

Anatomy

Pathophysiology

Osteoporosis is brought on by an imbalance between bone remodeling and resorption, which results in a loss of skeletal mass. Bone mass typically reaches its peak in the third decade, following which bone resorption outpaces bone growth. Osteoporosis can result from bone loss speeding up or not reaching a normal peak bone mass.

Etiology

The process of aging and a drop in sex hormones are both factors that contribute to primary osteoporotic fractures. The bones show signs of microarchitecture degeneration, which causes loss of bone mineral content and increases the chance of fracture. Osteoporosis is secondary to another condition or its treatment.

Secondary osteoporosis affects men far more frequently than it does women. Glucocorticoids and anti-epileptic medications are two examples of drugs that might cause secondary osteoporosis. Although they haven’t been thoroughly explored, other drugs such as proton pump inhibitors, thiazolidines, and chemotherapeutic medicines are thought to play a role in osteoporosis.

Hyperparathyroidism, malabsorption, anorexia, hyperthyroidism, and overtreatment of chronic renal failure hypothyroidism, Cushing syndrome, and thus any condition that can result in prolonged immobility are diseases that can induce osteoporosis. Rapid bone mass loss can also result from secondary amenorrhea that lasts longer than a year due to a variety of factors, such as non-estrogen hormone treatment, low body weight, and severe exercise.

Aging, being under 128 pounds, smoking, being Asian or white, going through premature menopause, being inactive, and having a history of fractures from minor trauma or ground-level falls after the age of 40 are all possible causes of osteoporosis. Within the first two weeks following these crippling injuries, patients with diseases like spinal cord accidents that compromise general mobility levels may see a significant decline in bone mass levels.

In the following, there is a high chance of fracture:

• Mature age
• Prior experience with a fracture
• Gender: Female
• Corticosteroid use
• a low BMI
• History of smoking
• Added (Secondary) osteoporosis
• Consuming alcohol

Genetics

Prognostic Factors

The outcomes are positive if osteoporosis is identified and treated early. However, if the issue is left untreated, it can result in fractures and persistent pain. Exercise, a calcium-rich diet, and the use of bisphosphonates can all reduce the risk of osteoporosis.

Surprisingly, bisphosphonates not only cost a lot of money but also have adverse effects. Additionally, it is still up for debate whether they will lessen fractures. In general, postmenopausal women continue to have a significant chance of developing a broken hip, which frequently necessitates extended recuperation and care home placement.

Another frequent injury is vertebral fracturing, which increases the risk of pneumonia, kyphosis, persistent discomfort, and respiratory problems. Due to their inability to perform, the majority of patients lose their capacity to live freely.

Clinical History

Age Group:  

While osteoporosis can affect people of any age, postmenopausal women and older men are the most likely to be affected. 

Associated Comorbidity or Activity:   

Fractures are more common in cases of osteoporosis, especially in the hip, spine, and wrist. Particularly in older people higher chances of osteoporosis and osteoarthritis frequently coexist.  

Joint stiffness and discomfort are common symptoms of osteoarthritis, a disorder marked by the deterioration of joint cartilage and the underlying bone. 

Osteoporosis patients have weakening bones and poorer balance, which puts them at higher risk of falling.  

Acuity of Presentation:  

Because it usually exhibits no symptoms in its early stages, osteoporosis is sometimes referred to as a silent disease.  

A low-trauma fracture, such as one sustained in a little fall or even from routine everyday tasks like bending or lifting, is typically used to diagnose osteoporosis.  

Osteoporosis patients sometimes have bone discomfort, especially in the wrists, hips, and back. This pain may intensify with movement or weight-bearing activities and manifest as dull, aching, or acute pain. 

Physical Examination

• Neurological Examination: Although osteoporosis mostly affects the bones, nerve discomfort or compression can occasionally result from consequences such spinal fractures.  
• Musculoskeletal assessment: To check for signs of other musculoskeletal disorders linked to osteoporosis, such as pain, deformities, and restrictions in joint range of motion. 
• Evaluation of Fracture Risk: The physician may ask about the patient’s past fractures, falls, and any family history of osteoporosis as well as any low body weight, smoking, excessive alcohol use, advanced age, and female gender. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

• Osteomalacia: This condition is defined by the softening of the bones because of poor mineralization. It usually occur of deficiencies in vitamin D or problems with the metabolism of vitamin D.  
• Osteogenesis imperfecta: It is characterized by fragile bones that are easily fractured. Individuals who may have milder symptoms of the illness can still be diagnosed with it. 
• Metabolic bone disorder: Lowered bone density can result from conditions including hypothyroidism, hypercalcemia, hypophosphatemia, and hyperthyroidism. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

• Lifestyle Modifications: Adequate intake of calcium and vitamin D is essential for bone health.  
• Regular weight-bearing and muscle-strengthening exercises: Activities such as walking, jogging, dancing, and resistance training help maintain bone density and improve balance and coordination to reduce the risk of falls. 
• Fall prevention strategies: Minimizing fall risks at home, such as removing hazards, using assistive devices, and improving lighting, can help prevent fractures in individuals with osteoporosis. 
• Management of Underlying Medical Conditions: Treating underlying medical conditions that contribute to bone loss, such as hyperthyroidism, hypogonadism, or vitamin D deficiency, is essential for optimizing bone health. 
• Regular Monitoring and Follow-Up: Bone mineral density testing: Regular monitoring of bone density using dual-energy X-ray absorptiometry (DXA) scanning helps assess treatment response and guide therapeutic decisions. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-non-pharmacological-approach-for-osteoporosis

• Remove Hazards: Identify and remove potential hazards in the home that could increase the risk of falls, such as loose rugs, electrical cords, clutter, and slippery surfaces.  
• Install Grab Bars and Handrails: Install grab bars and handrails in key areas such as bathrooms, stairways, and hallways to provide support and stability. 
• Ensure Adequate Lighting: Proper lighting is essential for preventing falls. Install bright lighting in hallways, stairways, and frequently used areas to improve visibility, especially at night.  

• Use Assistive Devices: Depending on individual needs, consider using assistive devices such as canes, walkers, or mobility aids to provide additional support and stability, particularly when walking outdoors or on uneven surfaces. 
• Adjust Height of Objects: Store frequently used items within easy reach to avoid the need for reaching or bending over, which can increase the risk of falls. 

Role of Parathyroid Hormone Analogs

Teriparatide: It acts as an anabolic agent, meaning it promotes bone formation. It does this by stimulating osteoblast activity, which are the cells responsible for building new bone. 

Role of Selective Estrogen Receptor Modulator

• Raloxifene: It works by selectively binding to estrogen receptors in bone tissue, mimicking some of the beneficial effects of estrogen without stimulating the estrogen receptors in other tissues like the breast or uterus.
• It helps to maintain bone density by inhibiting bone resorption and promoting bone formation, resulting in an overall increase in bone mineral density.  

Role of Monoclonal Antibodies

• Denosumab: It is a monoclonal antibody that targets a protein called RANK ligand (RANKL), which is involved in the process of bone resorption.
• Denosumab prevents the activation of osteoclasts, the cells responsible for breaking down bone tissue, leading to decreased bone resorption and increased bone density. 

Role of Vitamins

• Vitamin D: It enhances the absorption of calcium from the intestines which ensures an adequate supply of calcium for bone mineralization and remodelling.
• Vitamin D promotes the mineralization of bone tissue by facilitating the deposition of calcium and phosphorus into the bone matrix. This process helps maintain bone strength and density, reducing the risk of fractures. 

Role of Calcium salts

• Calcium Citrate: It is an essential mineral for bone health, and adequate intake is important for maintaining bone density and strength. 
• Calcium supplements, including calcium citrate, are often recommended for individuals who do not obtain enough calcium from their diet alone. 

use-of-intervention-with-a-procedure-in-treating-osteoporosis

• Vertebroplasty: Vertebroplasty is a minimally invasive procedure used to stabilize vertebral compression fractures caused by osteoporosis or other conditions.
• The procedure is typically performed under local anesthesia and sedation on an outpatient basis. Vertebroplasty can provide rapid pain relief and improve functional outcomes in individuals with painful vertebral fractures. 

• Kyphoplasty: Kyphoplasty is a similar minimally invasive procedure used to treat vertebral compression fractures, but with the additional step of balloon-assisted vertebral augmentation.
• Kyphoplasty aims to not only stabilize the fracture but also restore vertebral height and reduce spinal deformity. 

use-of-phases-in-managing-osteoporosis

• Assessment and Diagnosis: The initial phase involves assessing the patient’s risk factors for osteoporosis, such as age, gender, medical history, medications, lifestyle factors, and family history of fractures. 

• Fracture Risk Assessment: Once diagnosed, the patient’s fracture risk is assessed using validated tools such as the Fracture Risk Assessment Tool (FRAX). This assessment considers various risk factors, including BMD, age, gender, prior fracture history, and other clinical factors. 
• Lifestyle modifications: Such as adequate calcium and vitamin D intake, weight-bearing exercises, fall prevention strategies, and smoking cessation, are also emphasized. 
• Monitoring and Follow-Up: Patients undergoing treatment for osteoporosis require regular monitoring to assess treatment response, adherence, and potential adverse effects. 
• Long-Term Management: Osteoporosis is often a chronic condition requiring long-term management to maintain bone health and reduce fracture risk. 

Medication