OSTEOPOROSIS

MR. YOGENDRA MEHTA

Lecturer,(SWC)
TU IoM BNC, Biratnagar
Introduction
 Bone is continually remodeled throughout our lives in response to
microtrauma.

 Dense cortical bone and Cancellous bone(trabecular) differ in

their architecture but are similar in molecular composition and
have an extracellular matrix with mineralized and non-
mineralized components.

 Bone strength is determined by collagenous proteins and greater

concentration of calcium (mineralized osteoid).

 In adults, approximately 25% of trabecular bone is reabsorbed

and replaced each year.

 Osteoporosis is common in people over 50. Experts estimate that

half of all women and 1 in 4 men over 50 have osteoporosis.
 Introduction
 Osteoprotogerin:

- Osteoprotegerin is secreted by osteoblasts.

- OPG protects the skeleton from excessive bone resorption
by binding to RANKL and preventing it from binding to its
receptor, RANK.
- thereby increasing bone strength.
- Known as osteoclastogenesis inhibitory factor
- It binds to Osteoprotegerin Ligand, inactivating it and
preventing osteoclast development, ultimately impacting
bone density and strength.
 RANKL/RANK: Derived from T-cell activator of Dendritic cell.
- signaling regulates the formation of multinucleated
osteoclasts from their precursor.
- RANKL binds to RANK and inhibits osteoblastogenesis.
 Contd……
hematopoietic precursors mesenchymal cells

Derived from
Osteoclast Osteoblast
Produce
Receptors in cell membrane osteoprotogerin
RANK Bind
with
RANKL
Protect from
Excessive Resorption of Bone
Result
Formation of bone cells

Bone mass
 Contd……
RANKL: Receptor Activator of Nuclear factor Kappa
Beta legand

Osteoclast Osteocytes
contain Produce
Receptors in cell membrane Receptor that
activated present nuclear factor-
kappa B RANK Bind to receptors
Ligand(RANKL)
result them to
Formation & mature of Osteoclast
causes
Resorption of Bone
Inhibition of

Bone mass Formation of bone cells

 Contd…..
 Osteoporosis is a chronic, progressive disease of
multifactorial etiology and it is silent disease.
 Osteoporosis is a systemic skeletal disease characterized
by:
 low bone mass
 micro architectural deterioration of bone tissue.
 Enhance the bone fragility
 Increase the risk of fracture
 There is a change in the normal homeostatic bone
turnover i.e; rate of bone reabsorption is greater than the
rate of bone formation and resulting reduced total bone
mass.
 Osteoporosis by WHO: BMD T-score of -2. 5 SD or more
below
 Osteopenia: BMD: T-Score of -1.1 to -2.4
 Contd……

 Normal
Trabecular
Bone Mass

 Osteoporosisis
defined as reduction
in bone mass,
osteopenia and
reduction in
trabecular bone mass.
Contd……
 In women it is three times more common than men due to :
 Low Peak bone mass
 Hormonal changes at menopause
- Estrogen binds with estrogen receptor to promote the
expression of osteoprotegerin.
- Estrogen activate the osteoblastic activities.
Commonly involved bone : vertebral and wrist
Contd……
 Primary Osteoporosis:
- Occurs in meopausal women
- Failure to develop peak bone mass & Vit.D
- Excess use of caffiene, cigarrate, soft drink alcohol

Secondary Osteoporosis
- Result of corticosteroids excess of 5mg for more than 3 month
decrease the functions of osteoblast through inhibition of Insulin
like growth factor . It stimulate bone resorption.

- Depo inhibits the secretion pituitary gonadotropin resulting in

decreased production of estrogen.
 ETIOLOGY
S.N Primary Characteristics
Osteoporosis
Causes
1 Post •decrease estrogen level & Ca-
Menopausal osteopenia
•Decreased estrogen lead to increase
bone resorption
•accelerated bone loss, primarily from
trabecular bone
•Fractures of the distal forearm and
vertebral bodies common
2 Senile •Calcium deficiency
•Occurs in women and men older than
70 years
•Represents bone loss associated with
aging
•Fractures occur in cortical and
trabecular bone Wrist, vertebral
 ETIOLOGY Contd…….
S.N Secondary Example
Osteoporosis
Causes
5 Deficiency •Calcium deficiency
states •Protein deficiency
•Vitamin D deficiency
•Malabsorption

6 Medications •Anticonvulsants: changes in calcium

and bone metabolism
•vitamin D deficiency
•Furosemide:increased urinary
excretion of calcium
•Glucocorticoids and corticotropin
prednisone (≥5 mg/day for ≥3 month)
•Heparin (long term): causes bone loss
by decreasing bone formation
•Chemotherapeutic:leads to bone
loss
 PATHOPHYSIOLOGY
hematopoietic precursors mesenchymal cells

Derived from (Normal Homestatic bone turnover)

Osteoclast Osteoblast
contain conversely production of
Receptors in cell membrane Receptor that activated
present nuclear factor-kappa B
RANKL Bind to
Ligand(RANKL)
cause them to
Differentiate & mature in Osteoclast osteoprogerin
causes
Resorption of Bone
Result

Total Bone mass porous, brittle & fragile bone

 CLINICAL FEATURES
Features Cause

Loss of stature Due to vertebral compression

Abdominal distension Compression of spine, downward &
angulation of the ribs and significant
narrowing of the normal gap between
lower ribs and ileac crest.
Forward pelvic tilt with Due to loss of anterior lumber curve
shuffling unsteady gait
Extra abdominal crease Compression of spine, downward &
angulation of the ribs and significant
narrowing of the normal gap between
lower ribs and ileac crest.

Back pain after lifting, bending and increased with palpation

Kyphosis-Dowager’s hump,

Pathological fracture
KKYPHOSIS FRACTURE
 DIAGNOSIS
• History
• Clinical examination

-Examination of active and passive range of motion

(ROM) assists in determining whether spine, hip,
wrist, or other osseous pathology may be present.

-Thorough neurologic examination = to rule out spinal

cord and/or peripheral nerve compromise.

-Thoracic kyphosis with an exaggerated cervical

lordosis (dowager hump).
-Pain at fractured sites
 DIAGNOSIS Contd……..
• CT Scan- Widened Haversian Canal with thin
Trabeculae
• Laboratory test-
Blood Biochemistry:
-Sr, Calcium , Sr. Phosphate, Sr. Alkaline
phosphatase, Protien-Normal in primary
osteoporosis
- Creatinine= Increased

Liver function Test:

Increase level of alanine aminotransferase (ALT),
aspartate aminotransferase (AST), gamma-glutamyl
transferase (GGT), bilirubin, and alkaline
phosphatase may indicate alcohol abuse .
DIAGNOSIS Contd……..
•X-ray-Chest, Spine, Pelvic- loss of density of bone and
thinning of cortices
 DIAGNOSIS Contd……..
 Hematological Test:
Hematocrit, Hb , ESR

 Bone biopsy

 BMD
 DEXA(Dual energy X ray
absorptiometry: it gives
indication of normal or
osteopenic or osteoporosis
 TREATMENT
 Conservative :
-Dietary supplement: Calcium and
Vitamin D, high protein diet
-Low-fat dairy products
-Dark green leafy vegetables
-Canned salmon or sardines with
bones
-Soy products, such as tofu
-Calcium-fortified cereals and orange
juice
-Regular weight bearing exercise:
20-30 minutes of aerobic exercise(
promote bone formation).
-Suitable support for the spine to
preventfrom further kyphosis
developing
- Discourage for smoking and
alcohol intake
 TREATMENT Contd……
• Pharmacological:
Hormonal Therapy: raloxifene, and estrogen
Anti-osteoporotic drug:
Bisphosphonates:
-Zoledronic acid
- Alendronate (Fosamax)
-Risedronate (Actonel, Atelvia)
-Ibandronate (Boniva)
CalcitoninTherapy:
by Nasal spray or IM or Subcutaneous- inhibits
osteoclast=reducing loss of bone.
• Management of Fracture
 TREATMENT Contd……
Denosumab
 produces similar or better bone density results
and reduces the chance of all types of fractures.
 Denosumab is delivered via a shot under the
skin every six months.
Recent research indicates there could be a high
risk of spinal column fractures after stopping
the drug.
 TREATMENT Contd……
Bone-building medications
Severe osteoporosis or if the more common
treatments for osteoporosis don't work well enough
then:
• eriparatide (Bonsity, Forteo):stimulates new bone
growth. It's given by daily injection under the skin for
up to two years.
• Abaloparatide (Tymlos) is another drug similar to
parathyroid hormone. This drug can be taken for only
two years.
• Romosozumab (Evenity): It is given as an injection
every month at doctor's office and is limited to one
year of treatment.

After you stop taking any of these bone-building

medications, you generally will need to take another
 SURGICAL PROCEDURE

Vertebroplasty and
balloon kyphoplasty

- indicated in patients with

incapacitating and persistent
severe focal back pain related
to vertebral collapse
PREVENTION
NURSING ASSESSMENT
 History concerning the osteopenia i.e family history,
H/o previous fracture, dietary consumption
 Exercise pattern
 Onset of menopause
 Use of steroids
 Alcohol , smoking and caffeine intake
 H/o Back pain, constipation, altered gait
 O/E-
- Fracture,pain
- Kyphosis of thoracic spine
- Shortened stature
- Decreased mobility
- Difficulty in breathing
NURSING ASSESSMENT
 Have you broken bones?
 Have you gotten shorter?
 How is your diet, especially your dairy intake? Do
you think you get enough calcium? Vitamin D?
 How often do you exercise? What type of exercise
do you do?
 How is your balance? Have you fallen?
 Do you have a family history of osteoporosis?
 Has a parent broken a hip?
 Have you ever had stomach or intestinal surgery?
 Have you taken corticosteroid medications
(prednisone, cortisone) as pills, injections or
creams?
THANK
THANK
YOU YOU