Osteoporosis

Dr. C. C. Visser
MBChB MMed (Med Phys)
Diploma Musculoskeletal Medicine (UK)
Member: Society of Orthopaedic Medicine (UK)
Effect of age on
trabecular bone. Fat-
free dry bone
cylinders obtained
from the iliac crest of
a 20- (a) and a 60-
year-old person (b).
Dowager’s hump.
Marked thoracic
kyphosis due to
multiple osteoporotic
fractures in elderly
woman.
Dowager’s hump.
Marked thoracic
kyphosis due to
multiple osteoporotic
fractures in elderly
woman with
corresponding
radiograph.
Diagnosis
Changes in vertebral
shape due to
osteoporosis. Normal
vertebra (1), wedge
fracture (2), biconcave
or ‘fish’ vertebra (3),
and a compression
fracture (4).
Osteoporotic fracture.
Radiograph illustrating
radiolucency, Schmorl’s
node, wedge and
compression fractures
Treatment
Stress Fractures
 Stress Fractures
• Partial/complete fracture of cortical/cancellous
bone due to its inability to withstand rhythmic
nonviolent stress applied repeatedly in a
submaximal manner
• Often associated with muscle overloading /
fatigue→ reduction in shock absorption →
redistribution of forces to the bone
• 5 % of all sports injuries (Recreational and well
trained athletes): 75% are tibial / tarsal
 Types of Stress Fracture
• Fatigue stress #: abnormal repetitive load
applied to normal bone

• Insuffiency stress #: normal stressing of

abnormal bone (osteoporosis/osteomalacia)

• Combinations can exist

 Predisposing factors
• Risk factors for osteoporosis
– Female
– Amenorrhoea
– Poor diet
– Caucasian
• Poor fitness with rapid progression in training
• Biomechanical abnormalities esp excessive
pronation/foot rigidity
 Pathology
• Normally equilibrium between osteoblastic
and osteoclastic activity
• Controlled loading of bone: increase in
osteoblastic activity giving greater bone
density and strenght (stress reaction)
• Repeated overloading of bone: increase in
osteoclastic activity with weakening and
eventually failure of bone (stress #)
 Bone response to stress
Heals or
Forms localized area of mature periosteal and endosteal
hyperostosis (cortical hypertrophy = stress reaction) if
bone response is greater than demands on bone or
Develops stress #
Stress on bone leads to progressive deformity
If deformity within elastic range, bone returns to original
configuration when deforming force relaxes
If stressed beyond elastic range, permanent deformity due to
microfractures
If continued stress, number of stress # increases and progresses
leading to structural failure (stress#)
 Common sites
• Sesamoids:
– Medial-middle to distal: standing, running, football
• Metatarsal
– 2nd, 3rd-shaft: running, marching, ballet, skating
– 5th-distal to tuberosity:running, basketball
• Navicular central third-dorsal and
proximal:basketball, running
• Calcaneus posterior-dorsal:running, jumping,
marching
• Tibia
– Posterior-junction of proximal and middle/junction of
distal and middle thirds: running, marching, aerobics,
ballet, basketball
– Anterior-midshaft: ballet, basketball, running
• Fibula
– Proximal: jumping, parachuting
– Supramalleolar: running, marching
• Patella midpole: jumping, basketball, hurdling
• Femur
– Neck: running, long distance running, ballet
– Shaft-junction proximal and middle thirds: long
distance running, ballet
• Pelvis junction of pubis and ischium: long
distance running
• Sacrum proximal: running, aerobics
• Spine (lumbar): ballet, gymnastics, running,
weight lifting
• Ribs
– 1st: backpacking, weight lifting, pitching
– Lower ribs: golf, rowing
• Clavicle medial: carrying heavy weights
• Scapula coracoid: golf, shooting
• Humerus shaft: pitching, tennis, wrestling,
shotputting
• Radius shaft: pitching
• Ulna shaft: shoveling, rowing, pitching,
body building, wheelchair athletics
• Hamate hook: golf, tennis, batting
• Scaphoid waist: shotputting, gymnastics
 Symptoms and Signs

• Severe pain in region: aggravated by activity, initially

relieved by rest but later not any more
• Tenderness over site
• Swelling and increased warmth if # in superficial bone
• Palpable localized periosteal thickening in chronic cases
• Loading bone will cause pain eg hopping on injured leg
• Fulcrum test of long bones: pressure on bone away
from # site will cause pain at the site
 Investigations: X-ray’s
• 25% accurate early on
• Changes occur between 2 weeks and 3 months
• Cancellous bone eg calcaneus, long bone ends:
– Linear radiodense area orientated perpendicularly to the
trabeculae (=collapsed trabeculae, osteoblastic activity,
endosteal callus)
• Cortical bone:
– Radiolucent line within an area of cortical hyperostosis
– Line either perpendicular or parallel to the long axis of
the bone
– Not always visible if the surrounding localised stress
response is massive: try overpenetrated X-rays,
tomography, CT, MRI
Stress reaction with cortical
hyperostosis
Stress fractures of the
fibula in RA. Radiography
of the right ankle and foot
shows severe
osteoporosis, rheumatoid
deformity with a valgus
hindfoot and a healed
stress fracture of the lower
part of the fibula with
extensive callous
formation.
Stress fracture of the fibula
in RA. Radiography of the
knee joint shows erosive
RA resulting in a valgus
deformity of the joint and
extensive destruction of
the lateral compartment.
The resulting mechanical
stress has led to an oblique
fracture in the upper part
of the fibula.
 Investigations: Tc-Bone scan
• Nearly 100 % diagnostic
• May be positive within 6-72 h after onset of
pain
• Triple phase bone scan (blood flow, soft
tissue hyperaemia, bone turnover):
– old vs new #
– partial vs complete #
– soft tissue lesions vs bony lesions
 Investigations: MRI and CT
• MRI: nonspecific and too expensive
– Bone marrow oedema
– Perisoteal reactiobn
– Fracture (not always)
• CT:
– Nonunion of tarsal stress fractures:
• Initially ill-defined area of mildly increased cortical activity
• Spreads into medulla and is highly active
• Sreads to the opposite cortex and becomes intensely active
– Seldom required in most stress fractures
 Treatment
• Cease all activity involving injured bone
• Weightbearing bones: partial/nonweight
bearing
• Immobilisation seldom required except in
tarsal #
• Certain femur neck # may require internal
fixation
 Complications
• Complete fracture, especially
– Femoral neck :
• medial aspect just proximal to lesser trochanter
• linear radiodense region orientated perpendicularly to long axis
of bone ie cortical pattern
– Navicular:
• # in saggital plane at junction of middle and lateral thirds
• difficult to see on X-ray, do Tc scan/CT/MRI
• Can lead to nonunion / ischaemic necrosis of lateral fragment
• Delayed union/nonunion:
– sclerosis bordering fracture margins partially or
completely
– Flat/irregular bones like ischium & ribs, navicular, ant
cortex of mid tibia, base of 5th MT distal to the
tuberosity
• Contralateral injuries