Osteoporosis and Osteopenia

Osteoporosis vs. Osteopenia

• Osteopenia is a condition characterized by lower bone density than normal for a person's age, indicating a decrease in bone mass and increased porosity.
• Osteoporosis is a more severe condition than osteopenia, leading to weakened bones that are more susceptible to fractures.
• Osteoporosis is often associated with hormonal changes, especially in post-menopausal women, as well as calcium or vitamin D deficiencies.
• Bone mineral density is measured using a DEXA scan, which is an X-ray that quantifies bone density.
• A T-score from a DEXA scan indicates bone density, where scores greater than -1 are considered normal.
• T-scores between -1 and -2.5 indicate osteopenia
• T- scores of -2.5 or lower indicate osteoporosis

Clinical Manifestations and Treatment of Osteoporosis

• Clinical signs of osteoporosis include decreased height, fractures (especially compression fractures), and kyphosis.
• Bisphosphates are a class of medications used to treat osteoporosis by drawing calcium from the blood and depositing it back into the bones, increasing bone density.

Rickets and Osteomalacia

• Rickets is the softening and weakening of bones in children, while osteomalacia is the same condition occurring in adults.
• These conditions are typically caused by deficiencies in vitamin D, calcium, or phosphate.
• While rare in the U.S., rickets remains a significant health issue in underdeveloped countries.
• Rickets can be prevented through vitamin D supplementation and a diet rich in vitamin D.
• Softened bones from rickets or osteomalacia are prone to bowing and fractures.
• Diagnosis involves blood tests to check calcium and phosphorus levels, X-rays, and bone biopsies.
• Treatment primarily involves supplementation to address the underlying deficiency.

Paget's Disease

• Paget's disease is a progressive condition characterized by abnormal bone destruction and remodeling, leading to bone deformities.
• The cause of Paget's disease is unknown, and while there is no cure, treatment can help manage the condition.
• Paget's disease is more common in individuals over 40, with incidence rates doubling each decade.
• It is also more prevalent in men than in women.
• Clinical signs can include bone pain, headaches, tingling, numbness in the arms and legs, and bent bones.
• Complications can include fractures, deformities, osteoarthritis, and bone cancer.
• Diagnosis involves blood tests, X-rays, and bone scans.
• Treatment includes bisphosphates, similar to osteoporosis treatment.

Osteomyelitis

• Osteomyelitis is an infectious bone disease characterized by inflammation or swelling in the bone.
• Bacteria entering from outside the body, such as through a wound, open fracture, or surgical procedure, typically causes it.
• Osteomyelitis is more common in young children (under 5) and older adults.
• Clinical signs include bone pain and inflammation.
• Treatment commonly involves surgical debridement, culture, and antibiotics.
• MRSA (methicillin-resistant Staphylococcus aureus) is a common causative bacterium.

Osteoarthritis (OA) vs. Rheumatoid Arthritis (RA)

• Osteoarthritis is a degenerative and progressive joint disorder resulting from the destruction of normal collagen due to wear and tear.
• Rheumatoid arthritis is a chronic autoimmune inflammatory disorder affecting many joints, including those in the hands and feet.
• OA affects 30 million people in the U.S., with incidence increasing with age and obesity, and is common in individuals 40 and older.
• RA affects about 6 million people in the U.S., with 75% of cases occurring in women.
• The cause of RA is multifactorial and often autoimmune.
• OA affects joints asymmetrically, particularly large weight-bearing joints like the knees and hips, with pain increasing throughout the day.
• RA affects joints symmetrically, with pain often improving as the day goes on.
• Diagnosis of OA involves plain X-rays and joint fluid analysis, with no specific lab work.
• Diagnosis of RA involves physical exams, blood work (inflammatory markers and rheumatoid factor), and imaging. Lifestyle modifications are key to its management, as well as anti-inflammatory medicines, physical therapy and supportive devices

Clinical Features: OA vs. RA

• OA treatment focuses on symptom relief, maintaining function, limiting disability, and avoiding drug toxicity, including lifestyle changes such as weight loss and exercise.
• RA management involves NSAIDs for pain and inflammation, as well as disease-modifying anti-rheumatic drugs (DMARDs) like Methotrexate and TNF inhibitors like Enbrel and Humira.
• In OA, there is thinning cartilage and osteophytes (bone spurs), which are not common in RA.
• RA involves bone erosion and swollen, inflamed synovial membranes, with swelling, redness, and heat in the synovial membrane.
• On X-rays, osteophytes indicate degeneration associated with osteoarthritis.

More Clinical Feature Details

• Rheumatoid arthritis primarily affects metacarpophalangeal and proximal interphalangeal joints, often leading to ulnar deviation.
• Osteoarthritis primarily affects distal interphalangeal and carpometacarpal joints.
• Heberden's nodes and Bouchard's nodes (nodes on the finger joints) are absent in RA but frequently present in OA
• RA joints are soft, warm, and tender to the touch due to inflammation, while OA joints are hard and bony.
• Stiffness worsens after rest in RA, improving as the day progresses, while stiffness in OA worsens after effort, often described as evening stiffness.

Gout

• Gout is an inflammatory disorder caused by elevated levels of uric acid in the blood and body fluids, including synovial fluid.
• Uric acid crystals form in the joints, causing inflammation.
• A defect in purine metabolism can cause gout.
• Subjective signs as pain, swelling, redness, heat, stiff joints, and night pain
• Gout attacks abruptly happen in a peripheral joint, 50% occuring in the great toe joints.
• Kidney stones are much more common in patients with gout compared to the general population.
• Diagnosis involves history, blood work, and joint fluid samples.
• Management includes medications like colchicine, corticosteroids, NSAIDs, and allopurinol.
• Patients should avoid foods high in purines, such as shellfish, alcohol (especially beer), and organ meats, to prevent gout attacks.

Fibromyalgia

• Fibromyalgia is a chronic musculoskeletal syndrome characterized by widespread muscle pain and tenderness, as well as joint tenderness.
• It is extremely common, with 90% of those affected being women, and is typically diagnosed between the ages of 30 and 50.
• The pathophysiology is unclear, but it is common in people, particularly women, who may also have irritable bowel syndrome or chronic fatigue.
• Clinical signs include chronic muscle pain, fatigue, sleep problems, and painful tender points.
• Diagnosing Fibromyalgia involves a history and physical, as there are no positive inflammatory markers (normal CRP and sed rate).
• Treatment includes medications for comfort, physical therapy, water therapy, and rest.