Bone is a metabolically active organ system,
constantly tearing down old bone and replacing it with new. Osteoporosis
is an imbalance in this process, whether by inadequate production,
excessive removal, or both. The result is too little bone, though
what is there is qualitatively normal. In older women, there is
often an associated nutritional osteomalacia.
Fractures, whether "microscopic" or obvious, produce pain
in patients with osteoporosis. Back pain, primarily in the thoracolumbar
area, sometimes begins after a "pop" and usually radiates around
the ribs or along the iliac crest. Hip pain may indicate an impending
intertrochanteric, femoral neck, or pubic ramus fracture. Wrist
pain and wrist fractures are common after a fall. Other sites
vulnerable for fracture include the ankle and shoulder.
Dizziness, stroke, syncope, medication changes, alcoholism, use
of psychotropic medication, age-related loss of proprioception,
dementia, and external factors, such as loose rugs and electrical
cords, compromise balance and predispose patients to falls.
Wrist deformity (Colles fracture) following a fall is often the
first sign of osteoporosis, especially in women younger than 65
years. Kyposis (dowger's hump) is often severe as the disease
advances; this collapse of the spine with preservation of limb
length produces an appearance of a shortened trunk. The lower
rib cage may come to rest on the iliac crest. Fractures about
the hip precipitate most hospital admissions for osteoporosis.
There are several techniques for estimating bone mass and, with repeated
measurements, the rate of bone loss. However, none of these techniques will
establish an accurate rate of bone loss without mulitple (usually more than
three) annual measurements. Single measurements are valuable only to estimate
the patient's bone mass relative to an age-matched population. The results of
laboratory studies are usually normal; abnormalities, such as elevated alkaline
phosphatase, are commonly associated with fractures. Urinary calcium excretion
may be high in rapid bone resorption states. Untreated hyperparathyroidism may
cause osteopenia in younger patients.
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Prevention is the optimal treatment. Emphasis on adequate
calcium intake for teenage women and regular exercise to build
bone mass. Oral calcium taken in doses of 1,000 mg/day in premenopausal
years and 1,500 mg/day in postmenopausal years is appropriate.
Note that skim milk has the highest calcium content of the milk
group. Exercise is crucial to preserving bone mass and should
be started as soon as possible following diagnosis. Following
these two simple steps puts "money in the bank" by creating a
large peak bone mass for those later years when bone loss exceeds
formation.
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