is characterized by low bone mass and skeletal disruption, and leads to increased risk of fragility fractures (ie, fractures due to minimal trauma such as falls from a standing height).

Fragile fracture examples include acquired a rib fracture while coughing, which is considered a low-trauma fracture.

Demineralization and low bone density is often asymptomatic but increases the risk for fractures, most commonly involving the hip, vertebrae, and distal radius

• Risk factors

Significant fracture due to a ground-level fall is uncommon and often indicates underlying bone fragility due to osteoporosis.  The most common cause of osteoporosis is declining estrogen levels in women after menopause; the risk is significantly lower in men, and osteoporosis in a young or middle-aged man suggests a secondary cause.

• FRAX aassesment tool
• Secondary causes of osteoporosis

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Diffuse osteopenia can limit the appearance and detection of fractures on x-rays.

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• Screening for osteoporosis with dual-energy x-ray absorptiometry is recommended in all women age >65 and for younger women with an equivalent risk of osteoporotic fracture (e.g., prolonged glucocorticoid use, low BMI (< 21 kg/m2) or weight < 127 lb, alcohol use, smoking, amenorrhea).

• Clinical features of vertebral compression fracture

<aside> 💡 risk of fragiltiy fracture is highest in those with a prior history of fragility fracture

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• Treatment

DEXA scans should be repeated every 2 years for patients with osteopenia or osteoporosis.

Increased osteocalcin concentration is a marker of bone formation and is correlated with increases in bone mineral density, for example, when bone-forming medications such as teriparatide are used. While osteocalcin concentrations are increased in metabolic bone diseases with increased osteoid formation (including osteoporosis), bone density loss outpaces new bone formation in osteoporosis. Thus osteocalcin is normal in setting of osteoperosis.

• EDUCATIONAL OBJECTIVES

(Choice A) Calcium supplementation is commonly provided during bisphosphonate therapy to reduce the risk of hypocalcemia. However, calciumsupplementation has not been shown to reduce the risk of MRONJ. Since calcium forms complexes with bisphosphonates, it can reduce absorption, and neither supplements nor food should be taken within 60 minutes of oral bisphosphonate administration.

Osteoporosis is common in postmenopausal women due to accelerated bone loss from loss of estrogen. Initial laboratory evaluation (eg, complete blood count, metabolic panel including calcium, 25-hydroxyvitamin D) is aimed at ruling out secondary causes of bone loss. Additional work-up is indicated in patients with significant abnormalities on initial studies (eg, hypercalcemia).  In addition, nonlocalized bone pain and tenderness with no history of fracture (eg, osteoporotic vertebral compression fracture causing localized spine tenderness), as seen in this patient, are uncommon findings in postmenopausal osteoporosis and also suggest a secondary cause of bone loss (eg, osteomalacia, malignancy).

(Choice C)  Bisphosphonates are commonly used in patients with postmenopausal osteoporosis.  However, renal insufficiency is a contraindication to bisphosphonate therapy, and this patient requires additional evaluation before starting definitive treatment.

Choice E)  The prevalence of both hypertension and osteoporosis increases with age, and the conditions often coexist.  However, hypertension does not contribute to osteoporosis, and thiazide diuretics, commonly used in hypertension, may decrease the risk by reducing renal excretion of calcium.

(Choice F)  Hyperthyroidism can increase the risk of osteoporosis due to accelerated bone turnover.  Hypothyroidism is not a major risk factor unless untreated or if thyroid hormone is chronically over-replaced.