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By Dr Nitish Arora
Consultant Trauma Limb Reconstruction
Deformity Correction & Pediatric Orthopedic Surgeon
Overview Causes of osteoporosis Risk factors and symptoms Fracture prevention consists of bone health and prevention of falls Calcium and Vitamin D rich diet/Supplements Prevention of falls Management of osteoporotic fractures

Overview

Bones are essentially made up, a structural element called hydroxyapatite and a protein called collagen. Hydroxyapatite consists of small crystals of calcium and phosphorus and it provides stiffness to the bone. Collagen is a protein molecule which binds the hydroxyapatite crystals together and provides tensile strength to the bone. Osteoporosis is basically a skeletal condition which affects both these components of a bone in terms of decreased quality as well as quantity. This weakens the bone and makes them more prone to fracture even with minor fall.

Causes of osteoporosis

Primary osteoporosis

  • Type 1: Post menopausal osteoporosis (due to decline in estrogen production)
  • Type 2: Senile osteoporosis (age related weakening of bones)

Secondary osteoporosis

  • Drug Induced: Steroid
  • Endocrine disorders: Hyperthyroid
  • Chronic alcoholic
  • Cancers
  • Post Irradiation therapy

Risk factors and symptoms

Not modifiable

  • Female
  • Increasing age
  • Early menopause
  • Medications and medical conditions
  • Genetic factors

Modifiable

  • Lack of physical activity/obesity
  • Inadequate peak bone mass due to lack of Vit D and calcium rich foods
  • Smoking
  • Alcohol
  • High caffeine intake
  • High salt intake
  • Abuse of antacids

Symptoms

It is usually a silent disease until complicated by a fracture in the elderly.Most common sites of fracture include hip, wrist and spine fracture.

Do we need to sustain fracture to diagnose it?

No, to diagnose osteoporosis,In women age 65 and older and men age 70 and older, BMD/DEXA testing is recommended.

Recommend BMD testing to those who have suffered a fracture(hip, wrist or spine) to determine degree of disease severity.

Fracture prevention consists of bone health and prevention of falls

Bone health=Muscle health

Exercise:

A regular weight-bearing exercise regimen (for example, walking 30–40 min per session) along with back and posture exercises for a few minutes on most days of the week should be advocated throughout life.

Exercise effects must be site specific(different for back, gluteal i.e, muscles).

Calcium and Vitamin D rich diet/Supplements

  • Milk, cheese and other dairy foods
  • Plant-based drinks (such as soya drink) with added calcium.
  • Green leafy vegetables such as broccoli, okra and cabbage but not spinach.
  • Nuts
  • Soya beans/Ragi
  • Tofu
  • Bread and anything made with fortified flour.
  • Fish such as sardines and pilchards.
  • Sunlight, salmon, cod liver oil, egg yolk, sun dried mushrooms or vitamin D fortified food.
  • Calcium and vitamin D supplements must be started in childhood, adolescent, elderly and especially in females during peak bone mass age at around 30-35 years.
  • “MILK” is deficient in vitamin D. However it is a good source of calcium. Therefore its consumption should be limited to one or two glasses, especially in growing children, so that they are hungry enough to eat other nutritious things also.

Other general measures

  • Alcohol: Daily intake of 3 or more units of alcohol increases the risk of fracture.
  • In known osteoporosis/osteoporotic fracture: Do not consume more than 7 drinks/week; 1 drink being equivalent to 120 mL of wine, 30 mL of liquor, or 260 mL of beer.
  • Do not take oral glucocorticoids for 3 months (ever) without the doctor’s advice.
  • Stop abuse of antacids or some other medication (anticonvulsant) which increases the risk of osteoporosis and fracture.
  • Caffeinated drinks should be limited to no more than 1 - 2 servings (8 to 12 ounces in each serving) per day for patients.

Antiresorptive and anabolic medication

  • A group of medication either deposits more of the bone or prevents resorption from the bone.
  • To be started in consultation with an orthopedician.

Prevention of falls

Fall in the bathroom is the most common cause of fracture around the hip area

  • Improve lighting: on the staircase, along the corridor, night lamps, in the kitchen, bathroom etc.
  • Install grab bars near the toilet seat, in the bathing area.
  • Use non-slip mats outside the washroom, kitchen, bedroom, living room.
  • Install handrails along the stairs, corridor or any other area where you think it is required.
  • Remove all the obstacles or clutters from the floor or pathway where the elderly of our house are likely to use regularly.

Management of osteoporotic fractures

  • Management of osteoporotic hip fracture is of utmost priority in elderly people. It is because majority of these patients are not able to walk independently after the fracture, they have a high chance of sustaining opposite side hip fracture and some of them will develop life threatening complications (few will eventually succumb) like swelling the leg, clotting of blood in the lower leg veins, migration of these clots to lungs, bed sores, lung infections.
  • Timely management of these fractures can allow the patient to walk early (prevents developing above life threatening complications) and have near normal life as it was before the fracture.
  • A common scenario we usually observe: If an elderly in your house has fallen in a bathroom/or anywhere while walking and is unable to get up. Usually they will remain at home for days, develop swelling and other life threatening complications before they turn up at the hospital and are diagnosed to have fracture in the hip. Therefore, we request everyone to at least visit the nearby X-ray center or nearby hospital and get the X-rays done, if the elderly is not able to get up and walk after the fall, however minor it may be.

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