Learning objectives
- •
The diagnosis of low bone mass in young adults.
- •
Factors affecting peak bone mass.
The case study
Reason for seeking medical help
Mrs. RT, 24 years old, is referred because, about 6 months ago, she sustained a right Colles’ fracture of the distal radius while playing table tennis with her husband: she tripped and her right hand hit the table. The fracture was not displaced and healed well. She nevertheless is concerned she may have osteoporosis. She is essentially asymptomatic, has a free range of movement of the right wrist, and has no pain.
Past medical/surgical history
- •
No relevant medical or surgical history.
- •
Menarche at age 13 years, regular menstrual periods.
- •
Her weight has been steady. Her appetite is good. Her diet is well balanced.
- •
Good daily calcium intake from food, estimated at about 1200 mg daily.
Personal habits, lifestyle, daily routine
- •
She leads a healthy lifestyle: exercises regularly at least 1 h three times a week in a gymnasium. She has a personal trainer.
- •
No cigarette smoking. She consumes alcohol only in moderation, not exceeding an occasional glass of wine with dinner, once or twice a week.
- •
Drinks neither coffee, nor soda drinks.
Medication
- •
No medication intake, except for the occasional multivitamin tablet, when she remembers to take it!
- •
She stopped taking the ibuprofen and acetaminophen tablets prescribed after she sustained the Colles’ fracture.
- •
No over-the-counter medication.
Family history
- •
Negative for osteoporosis and fractures.
- •
Negative for bone diseases.
Clinical examination
- •
She is 5′4″ tall, weighs 128 pounds.
- •
BP 112/72 sitting and 116/74 on standing up. No clinical evidence of orthostasis.
- •
No relevant clinical signs.
Laboratory investigations
- •
CBC and CMP within normal limits.
- •
Serum vitamin D: 44 ng/mL.
- •
Serum thyroid stimulating hormone: within the normal range.
DXA scan
- •
Low bone mineral density for given age: lowest Z -score: −2.3 in upper 4 lumbar vertebrae.
Multiple choice questions
- 1.
The diagnosis of osteoporosis in young adults:
- A.
There are clear, well-defined clinical criteria to diagnose osteoporosis in young adults.
- B.
Imaging studies are available to confirm the diagnosis of osteoporosis in young adults.
- C.
Specific laboratory tests are available to confirm the diagnosis of osteoporosis in young adults.
- D.
A and B.
- E.
None of the above.
Correct answer: E
Comment:
Unlike osteoporosis in postmenopausal women and older people, the diagnosis of osteoporosis in young adults is nebulous, ill-defined, largely subjective, and open to misinterpretation. There is nevertheless consensus that a fragility fracture occurring in any age group is, per se, diagnostic of osteoporosis and is a required event to diagnose osteoporosis in young people. The definition of a fragility fracture is a fracture resulting from trauma that ordinarily would not be expected to cause a fracture, or occurring spontaneously, in the absence of trauma: atraumatic fracture. These issues are discussed in the section discussing the diagnosis of osteoporosis.
- A.
- 2.
A low bone mass in young adults could be due to:
- A.
A number of chronic diseases preventing the expected peak bone mass from being reached.
- B.
A number of lifestyle issues preventing the expected peak bone mass from being reached.
- C.
A genetically determined low peak bone mass.
- D.
All of the above.
- E.
None of the above.
Correct answer: D
Comment:
A number of factors may prevent an individual person from reaching the genetically predetermined peak bone mass, including diseases and lifestyle choices that may lead to secondary osteoporosis. Some of these are discussed in a different section. Once peak bone mass is reached and the epiphyses fuse, there is little subsequent bone growth, although through the processes of bone turnover, i.e. bone resorption and bone formation, the bone mineral content (BMC) and bone mineral density are constantly changing to strengthen individual bones, maintain their integrity, and prevent fractures, in spite of the exposure to an increased work load.
It is well known that bones in the dominant arm of tennis players are denser than the same bones in the nondominant arm. Similarly, the bones of hemiplegic patients tend to be less dense in the paralyzed than nonparalyzed side.
- A.
- 3.
Common causes of secondary osteoporosis include:
- A.
Vitamin D deficiency.
- B.
Hyperparathyroidism.
- C.
Juvenile rheumatoid arthritis.
- D.
Any of the above.
- E.
A and C.
Correct answer: D
Comment:
Any of the above mentioned can lead to secondary osteoporosis.
- A.
- 4.
Diseases affecting bone mass include:
- A.
Inflammatory bowel diseases.
- B.
Type I diabetes mellitus.
- C.
Secondary amenorrhea.
- D.
All of the above.
- E.
A and B.
Correct answer: D
Comment:
All of the diseases mentioned before affect bone mass, especially if they develop before the epiphyses fuse. Approximately 50%–80% of the variation in bone mass and structure among individuals is governed by heredity.
The major causes of secondary osteoporosis can be grouped into 4 major categories: First, chronic inflammatory conditions such as inflammatory bowel disease, Celiac disease, juvenile rheumatoid arthritis, systemic mastocytosis, and HIV. Second, endocrinal diseases including type I diabetes mellitus, Cushing’s syndrome, hyperparathyroidism, hypoparathyroidism, hyperthyroidism, and hypogonadism. Third, medications such as glucocorticoids, proton-pump inhibitors, and anticonvulsants. Fourth, lifestyle choices including sedentary lifestyles and inadequate diet with low daily calcium and mineral intake, vitamin D deficiency, alcoholism, and cigarette smoking.
- A.
- 5.
Idiopathic osteoporosis in young people:
- A.
Affects young men and women.
- B.
Is due to a defect in bone formation.
- C.
Can be diagnosed only after excluding common secondary causes of osteoporosis.
- D.
A and C.
- E.
A, B, and C.
Correct answer: E
Comment:
Idiopathic osteoporosis of the young affects both genders. Common secondary causes of osteoporosis, especially hypogonadism, alcoholism, and medication-inducing osteoporosis, have to be excluded before making a diagnosis. The defect in bone formation leads to decreased bone mass acquisition and a higher bone turnover rate. Idiopathic osteoporosis is also seen in premenopausal women. Its pathophysiology is not yet fully understood.
- A.
- 6.
The following is/are true:
- A.
Pregnancy-associated osteoporosis affects about 25% of pregnant women.
- B.
Pregnancy is associated with an increased intestinal calcium absorption.
- C.
Lactation is associated with an increased intestinal calcium absorption.
- D.
B and C.
- E.
A, B, and C.
Correct answer: B
Comment:
Pregnancy-associated osteoporosis and fractures are rare and can cause severe back pain, fractures, loss of height, and disability. The etiology, pathogenesis, natural history, and management are not clearly defined. During pregnancy the mother’s intestinal calcium absorption is increased. It tends to return to normal levels during lactation. The mother’s body adjusts by increasing intestinal bone resorption and decreasing renal calcium excretion. It seems to respond well to denosumab.
- A.
- 7.
Postpregnancy osteoporosis may lead to:
- A.
Fractures.
- B.
Height loss.
- C.
Severe back pain.
- D.
All of the above.
- E.
None of the above; it is a benign, physiologic, self-limited condition.
Correct answer: D
Comment:
In addition to the above mentioned, postpregnancy osteoporosis may present as transient osteoporosis of the hip(s), sometimes complicated by fragility fractures of one or both hips.
- A.
- 8.
Management of osteoporosis in the young should include:
- A.
Correcting any underlying nutritional deficiency, especially vitamin D.
- B.
Adequate calcium and protein intake.
- C.
Increasing level of physical activity.
- D.
Treating any underlying condition.
- E.
All of the above.
Correct answer: E
Comment:
These are the sine qua non for the appropriate management of diseases and are discussed in various sections.
- A.
- 9.
The following diseases increase the risk of osteoporosis in young people:
- A.
Inflammatory bowel disease.
- B.
Type I diabetes mellitus.
- C.
Hyperthyroidism.
- D.
Rheumatoid arthritis.
- E.
All of the above.
Correct answer: E
Comment:
All of the above-mentioned diseases increase the risk of osteoporosis in young people.
- A.
- 10.
The following is/are correct:
- A.
The FRAX algorithm is valid for all ages, including young adults.
- B.
The relationship between BMD and fracture risk is well established in young adults.
- C.
Bone turnover markers are not useful while developing a management strategy for young people with osteoporosis.
- D.
Vertebral fractures are rare in men with idiopathic osteoporosis.
- E.
None of the above.
Correct answer: E
Comment:
All these statements are incorrect and are discussed in other sections.
- A.
Case summary
Analysis of data
Osteoporosis is rare in young people and is usually associated with a number of diseases. Postpregnancy associated osteoporosis may present with back pain and lead to increased fracture risk.
Diagnosis
- •
Low bone mass for given age.
- •
Status post right Colles’ fragility fracture.
Management recommendations
Further diagnostic tests
- •
None indicated at this stage.
Pharmacological treatment recommendations
- •
None indicated at this stage.
Follow-up recommendations
- •
A repeat DXA scan in 2–3 years to monitor the bone mass.
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