In osteoporosis, a metabolic bone disorder, the rate of bone resorption accelerates while the rate of bone formation slows down, causing a loss of bone mass. Bones affected by this disease lose calcium and phosphate salts and thus become porous, brittle, and abnormally vulnerable to fracture.
Osteoporosis may be primary or secondary to an underlying disease. Primary osteoporosis is commonly called senile or postmenopausal osteoporosis because it’s most common in elderly, postmenopausal women. (See Osteoporosis in men.)
The cause of primary osteoporosis is unknown; however, a mild but prolonged negative calcium balance, resulting from an inadequate dietary intake of calcium, may be an important contributing factor — as may declining gonadal adrenal function, faulty protein metabolism due to estrogen deficiency, and a sedentary lifestyle.
Causes of secondary osteoporosis include prolonged therapy with steroids or heparin, total immobilization or disuse of a bone (as with hemiplegia, for example), alcoholism, malnutrition, malabsorption, scurvy, lactose intolerance, hyperthyroidism, osteogenesis imperfecta, and Sudeck’s atrophy (localized to hands and feet, with recurring attacks).
Osteoporosis is usually discovered when an elderly person bends to lift something, hears a snapping sound, and then feels a sudden pain in the lower back. Vertebral collapse, producing a backache with pain that radiates around the trunk, is the most common presenting feature. Any movement or jarring aggravates the backache.
In another common pattern, osteoporosis can develop insidiously, with increasing deformity, kyphosis, loss of height, and a markedly aged appearance. As vertebral bodies weaken, spontaneous wedge fractures, pathologic fractures of the neck and femur, Colles’fractures after a minor fall, and hip fractures are all common.
Osteoporosis primarily affects the weight-bearing vertebrae. Only when the condition is advanced or severe, as in Cushing’s syndrome or hyperthyroidism, do comparable changes occur in the skull, ribs, and long bones.
Differential diagnosis must exclude other causes of rarefying bone disease, especially those affecting the spine, such as metastatic carcinoma and advanced multiple myeloma. Initial evaluation attempts to identify the specific cause of osteoporosis through the patient history. Diagnostic tests include the following:
❑ X-rays show typical degeneration in the lower thoracic and lumbar vertebrae. The vertebral bodies may appear flattened and may look denser than normal.
❑ Bone mineral density (BMD) shows demineralization. Loss of bone mineral becomes evident in later stages.
❑ Dual- or single-photon absorptiometry allows measurement of bone mass, which helps to assess the extremities, hips, and spine.
❑ Serum calcium, phosphorus, and alkaline phosphatase levels are all within normal limits, but parathyroid hormone level may be elevated.
❑ Bone biopsy shows thin, porous, but otherwise normal-looking bone.
Effective treatment aims to prevent additional fractures and control pain. A physical therapy program, emphasizing gentle exercise and activity, is an important part of the treatment. In women, estrogen, to be started within 3 years after menopause, may be given to decrease the rate of bone resorption; sodium fluoride, to stimulate bone formation; and calcium and vitamin D, to support normal bone metabolism. However, drug therapy merely arrests osteoporosis and doesn’t cure it.
Similar therapies are used in men. Testosterone replacement may be used to increase BMD in men with low levels. (It’s contraindicated in men with prostate cancer.) A digital rectal examination and prostate-specific antigen test are performed before therapy and yearly thereafter.
Weakened vertebrae should be supported, usually with a back brace. Surgery can correct pathologic fractures of the femur by open reduction and internal fixation. Colles’fracture requires reduction with plaster immobilization for 4 to 10 weeks.
The incidence of senile osteoporosis may be reduced through adequate intake of dietary calcium, regular exercise, and avoidance of smoking and excessive alcohol consumption. Medications for maintaining bone health include bisphosphonates (alendronate and risedronate), calcitonin, estrogens, and raloxifene.
Secondary osteoporosis can be prevented through effective treatment of the underlying disease, as well as by steroid therapy, early mobilization after surgery or trauma, decreased alcohol consumption, careful observation for signs of malabsorption, and prompt treatment of hyperthyroidism.
❑ Focus on the patient’s fragility, stressing careful positioning, ambulation, and prescribed exercises.
❑ Check the patient’s skin daily for redness, warmth, and new sites of pain, which may indicate new fractures. Encourage activity; help the patient walk several times daily.
❑ Perform passive range-of-motion exercises, or encourage the patient to perform active exercises. Make sure she regularly attends scheduled physical therapy sessions.
❑ Institute safety precautions, such as keeping side rails up. Move the patient gently and carefully at all times. Explain to the patient’s family and ancillary facility personnel how easily an osteoporotic patient’s bones can fracture.
❑ Provide a balanced diet, high in nutrients that support skeletal metabolism: vitamin D, calcium, and protein. Administer an analgesic and heat to relieve pain.
❑ Make sure the patient and her family clearly understand the prescribed drug regimen. Tell them how to recognize significant adverse reactions and to report them immediately. Also tell the patient to report any new pain sites immediately, especially after trauma, no matter how slight.
❑ Advise the patient to sleep on a firm mattress and to avoid excessive bed rest. Make sure she knows how to wear her back brace.
CLINICAL TIP: Thoroughly explain osteoporosis to the patient and her family. If they don’t understand the nature of this disease, they may feel that they could have prevented the fractures if they had been more careful.
❑ Teach the patient good body mechanics — to stoop before lifting anything and to avoid twisting movements and prolonged bending.
❑ Instruct the female patient taking estrogen in the proper technique for breast self-examination. Tell her to perform this examination at least once a month and to immediately report any lumps. Emphasize the need for regular gynecologic examinations. Tell her to report abnormal bleeding promptly.
Read excerpts from these other book chapters related to Bone symptoms:
Copyright Details: Handbook of Diseases, Copyright © 2008 Williams & Wilkins.
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Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5 
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