Updated: 7/9/2019

Osteopenia & Osteoporosis

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Introduction
  • Definition (main characteristics common to both osteopenia and osteoporosis)
    • age-related decrease in bone mass secondary to uncoupling of osteoclast-osteoblast activity
    • disrupted microarchitecture
    • WHO definition (see table below)
  • Epidemiology
    • incidence
      • 10 million Americans and 200 million people worldwide have osteoporosis
      • 34 million Americans have osteopenia
      • 1.5 million osteoporotic fractures occur each year
        • 700,000 are vertebral fractures
        • 300,000 are hip fractures
        • 200,000 are wrist fractures
    • demographics
      • male: female ratio is 1:4
        • men have a higher prevalence of secondary osteoporosis (60%) including
          • hypogonadism
          • glucocorticoid excess
          • alcoholism
      • age bracket
        • osteoporosis
          • postmenopausal osteoporosis is highest in women aged 50-70 years
          • senile osteoporosis begins after 70 years
          • secondary osteoporosis begins at any age
        • fractures
          • wrist fractures occur most commonly at age 50-60 years
          • vertebral fractures occur most commonly at age 60-70 years 
          • hip fractures occur most commonly at age 70-80 years
    • location of fractures 
      • vertebral body > hip  > wrist fractures
    • risk factors   
      • table of risk factors 
  • Pathophysiology
    • quantitative, not qualitative, disorder of bone mineralization
    • factors
      • failure to build peak bone mass as a young adult
      • bone loss in later life
  • Associated conditions
    • fragility fractures
      • direct relationship between degree of bone loss and fractures
      • kyphotic deformity can arise from verteberal body fractures 
      • pelvic ring insufficiency fractures most often treated with bed rest and analgesia
      • total hip arthroplasty with constrained components are a risk factor for fragility fractures 
  • Prognosis
    • prior fragility fracture is the strongest predictor of a future fracture from low energy trauma 
    • vertebral fractures
      • associated with 15% increase in 5-year mortality
      • associated with increased morbidity
        • back pain
        • loss of height
        • poor balance
        • respiratory compromise 
          • restrictive lung disease
          • pneumonia 
      • history of 1 vertebral fracture results in 5 fold increased risk of 2nd vertebral fracture and 5 fold increased risk of hip fracture
      • history of 2 vertebral fractures is the strongest indicated for further compression fractures in postmenopausal women 
    • hip fractures
      • associated with 20% increase in mortality
        • men have higher mortality rates following hip fractures than women
      • associated with increased morbidity
        • reduced quality of life
        • only one third of patients with hip fractures return to their previous level of function
      • history of 1 hip fracture results in up to 10 fold increased risk of 2nd hip fracture
    • FRAX score   
      • WHO fracture risk assessment tool that calculates the 10-year risk of hip fracture and 10-year risk of major osteoporosis-related fracture
      • factors include age, sex, personal history of fracture, low BMI, oral steroid use, secondary osteoporosis, parental history of hip fracture, smoking status and alcohol intake.
Classification
 
  Type I (Post menopausal) Type II (Senile)
Age group Post menopausal (highest incidence in 50-70 years old) >70 years old
Bone affected Almost exclusively trabecular Trabecular > cortical 
Bones fractured Distal radius and vertebral Hip and pelvis
Effect on calcium

Net negative change in calcium levels because of decreased intestinal absorption and increased urinary excretion of calcium. 

 Poor calcium absorption
Effect on Vit D Reduced circulating levels of total (but not free) 1,25 dihydroxyvitamin D.  -
 
Labs
  • 25 hydroxyvitamin D level
    • low 25 hydroxy cholecalciferol levels (25 hydroxy vit D) in patients sustaining low energy fractures 
Imaging
  • Radiographs
    • indications
      • suspicion of fracture
      • loss of height
      • pain in thoracic or lumbar spine
    • recommended views
      • lateral spine radiograph 
      • AP pelvis or hip
    • findings
      • thinned cortices
      • loss of trabecular bone
      • kyphosis
      • codfish vertebra
    • sensitivity and specificity
      • usually not helpful unless > 30% bone loss
  • Dexa Scan (Dual Energy Xray Absorptiometry)     
    • usually performed in 
      • lumbar spine: measures BMD from L2 to L4 and compiles scores
      • hip: measure BMD from femoral neck, trochanter, and intertrochanter region and compiles scores
    • sensitivity and specificity
      • most accurate with the least radiation exposure
Term Definition
BMD absolute, patient-specific score determined from certain anatomic areas
T score BMD relative to normal young matched controls (30-year-old women) 
Z score BMD relative to similar aged patients

Osteopenia

L2-4 lumbar density of 1 to 2.5  standard of deviations (T score -1 to -2.5) below the peak bone mass of a 25 year old individual
Osteoporosis L2-4 lumbar density > 2.5 standard of deviations (T score <-2.5)  below the peak bone mass of a 25 year old individual
 
Studies
  • Biopsy
    • after tetracycline labeling
    • indications
      • may be helpful to rule out osteomalacia
  • Histology
    • thinned trabeculae  
    • decreased osteon size
    • enlarged haversian and marrow spaces
    • osteoclast ruffled border
      • Increases osteoclast ruffled border seen with
        • PTH
        • 1,25 dihydroxy Vit D3
        • Prostaglandin E
      • flattened ruffled border seen with
        • Bisphosphonates
        • Calcitonin
Differential
 
  Osteoporosis Osteomalacia
Definition Reduced bone mass, normal mineralization Bone mass variable, reduced mineralization
Age Post menopausal (Type I) or elderly (Type II) Any age 
Etiology Endocrine abnormality, age, idiopathic, inactivity, alcohol, calcium deficiency Vit D deficiency or abnormal vit D pathway, hypophosphatemia, hypophosphatasia, renal tubular acidosis
Symptoms and signs

Pain and tenderness at fracture site

Generalized bone pain and tenderness
Xray Axial fracture predominance Appendicular fracture predominance, symmetric, includes pseudofractures (Looser zones)
Serum Ca Normal Low or normal
Serum PO4 Normal Low or normal
ALP Normal Elevated (except hypophosphatasia)
Urinary Ca High or normal Normal or low (high in hypophosphatasia)
Bone biopsy Tetracycline labeling normal Tetracycline labeling abnormal
 
Treatment
  • Nonoperative
    • lifestyle modification & vitamins
      • indications
        • calcium and Vitamin D
    • pharmacologic treatment 
      • indications
        • 2008 National Osteoporosis Foundation Guidelines for Pharmacologic Treatment of Osteoporosis suggests that pharmacologic treatment be considered for 
        • postmenopausal women and men >= 50yrs old with: 
          • hip/vertebral fracture
          • T score between -1.0 and -2.5 at the femoral neck/spine and 
            • 10-year risk of hip fracture ≥ 3% or 
            • 10-year risk of major osteoporosis-related fracture ≥ 20% by FRAX calculation
          • T score -2.5 or less at the femoral neck/spine.
      • pharmacologic agents
        • calcium and Vitamin D
        • bisphosphonates
        • Conjugated Estrogen-progestin hormone replacement (HRT)
        • Estrogen-only replacement (ERT)
        • Salmon calcitonin (Fortical or Miacalcin)
        • Raloxifene (Evista)
        • Teriparatide (Forteo)
  • Operative
    • osteoporotic vertebral compression fracture 
    • femoral neck fracture 
    • distal radius fracture 
Pharmacologic Agents
  • Bisphosphonates
    • 1st line therapy
    • indications for pharmacologic treatment
      • hip or vertebral fracture
      • T-score <2.5 at the femoral neck or spine (after exclusion of secondary causes)
      • low bone mass (T-score between -1.0 and -2.5) and 
        • 10-year probability of a hip fracture ≥ 3% or greater or 
        • 10-year probability of a major osteoporosis-related fracture ≥ 20% based on WHO algorithm
    • mechanism
      • accumulate at sites of bone remodeling and are incorporated into bone matrix
      • are released into acid environment once bone is resorbed, and are then taken up by osteoclasts
      • decrease osteoclastic bone resorption, flattening of osteoclast ruffled border and increased osteoclast apoptosis
      • renal excretion without undergoing metabolism
      • exact mechanism depends on presence of nitrogen on alkyl chain (see table below)
    • technique
      • improved rates of treatment when coordinated by treating orthopedic surgeon and referral to osteoporosis clinic is made 
      • DEXA scan and referral to endocrinologist 
    • outcomes
      • alendronate reduces the rate of hip, spine and wrist fractures by 50%
      • risedronate reduces vertebral and nonvertebral fractures by 40% (each) over 3 years
      • IV zolendronic acid reduces the rate of spine fractures by 70% and hip fractures by 40% over 3 years
 
Drug Indications Mechanism Effects Characteristics Contraindications/ Adverse Effects
Calcium & Vit D  prophylactic in all patients, best for Type II (senile)

Calcium reduces fracture risk by 34%.

Vit D supplementation reduces hip fracture risk by 10% and nonvertebral fracture risk by 7%.

High dose vitamin D (median, 800IU/d) reduces hip fractures by 24% and nonvertebral fractures by 30%.

daily calcium and Vitamin D requirements are as follows: 
  • Age 1-3yrs - 500mg/d
  • Age 4-8yrs - 800mg/d
  • Age 9-18yrs - 1000 to 1500mg/d  
  • Age >50 yrs- 1200 to 1500 mg/d calcium 
  • 800-1,000 IUs Vit. D 
 
Non-nitrogen containing Bisphosphonates T score <-2.5SD, fragility fracture of the hip, in both men and women Produce toxic ATP analog, 
  etidronate, clodronate, tiludronate
Esophagitis, dysphagia, gastric ulcers, osteonecrosis of the jaw (ONJ), atypical subtrochanteric fractures
Nitrogen containing bisphosphonates

T score <-2.5SD, fragility fracture of the hip, in both men and women

Inhibit farnesyl pyrophosphate synthase (mevalonate pathway)

Alendronate reduces vertebral fractures by 48% and nonvertebral fractures by 47%.

Risedronate reduces vertebral fractures by 65% and nonvertebral fractures by 39%.

Ibrandronate reduces vetebralfracture risk by 77%, hip fractures by 41% and nonvertebral fractures by 15%.

pamidronate, alendronate (Fosamax), risedronate (Actonel), zolendronate (Reclast), ibandronate (Boniva)

Esophagitis, dysphagia, gastric ulcers, ONJ, atypical subtrochanteric fractures
Conjugated Estrogen-progestin hormone replacement (HRT) in women with Type I (within 6 years of menopause)
  Decreased the risk of hip fracture, but it also led to small increases in a woman's risk of breast cancer, CAD and heart attack, stroke, PE, DVT, and Alzheimer's disease  
Estrogen-only replacement (ERT) indicated for women with prior hysterectomy 


  Estrogen receptors are present on osteoblasts and osteoclasts Taking unconjugated estrogen (alone) increases the risk of endometrial hyperplasia / uterine cancer) 
Testosterone Men with low levels of testosterone
  Not yet approved by FDA for osteoporosis  

Salmon calcitonin (Fortical or Miacalcin)

Women >5y postmenopause, decreases pain in acute vertebral compression fractures (acts as neurotransmitter) Binds membrane receptors on osteoclasts to inhibit resorption   Injection or nasal spray (destroyed by gastric acid) Intranasal - Transient rhinitis. Injectable - nausea, vomiting, flushing, hypersensitivity reactions
Raloxifene (Evista) Women Agonist on estrogen receptors in bone (reduce osteoclast resorption). Antagonizes estrogen receptor in breast, reducing breast cancer risk.
  Selective estrogen receptor modulator (SERM), slows bone resorption and mild increase in bone thickness. Reduces risk of vertebral fractures only (not non-vertebral fractures).  Hot flashes, leg cramps. Contraindicated in patients with VTE 
Teriparatide (Forteo)  Severe osteoporosis/high fracture risk Receptors on osteoblasts (activates osteoblasts) and renal tubule cells, also stimulates intestinal absorption Ca and PO4  

1-34 amino terminal residues of parathyroid hormone (1-84)   ; given by daily subcutaneous injections (continuous infusion leads to bone resorption)  

Transient hypercalcemia, dizziness, nausea, headache.

 Contraindicated in Paget's disease due to potential osteosarcoma risk  

Denosumab (Prolia)   Postmenopausal women at high risk of fracture Monoclonal Ig2 against RANKL (inhibits binding of RANKL to RANK, like osteoprotegerin) Reduced vertebral fractures by 68%, hip fractures by 40%, nonvertebral fractures by 20%. SC injection to arm, thigh, abdomen

Arthralgia, nasopharyngitis, back pain. 

Contraindicated in severe hypocalcemia

Romosozumab (Evenity) Postmenopausal women with history of osteoporotic fracture, multiple risk factors for fracture, or who have failed or are intolerant to other osteoporosis therapy Humanized monoclonal Ig2 that activates Wnt pathway by bindsing sclerostin (sclerostin normally inhibits Wnt pathway). Promotes bone formation and inhibits resorption. Reduced new vertebral fracture by 73% through month 12 and by 75% through month 24  SC injection monthly Hyperostosis, cardiovascular events, osteoarthritis, and cancer, osteonecrosis of the jaw, atypical femoral fracture 
 
Complications
  • Osteonecrosis of the jaw (ONJ) is associated with IV bisphosphonates (but not oral bisphosphonates)
    • incidence
      • rare
    • treatment
      • stop bisphosphonates
  • Atypical subtrochanteric transverse stress fractures (in patients on long-term bisphosphonates) 
    • incidence
      • rare
    • mechanism
      • extremely low bone turnover rates
      • shown by reduced markers of bone resorption (e.g. urinary collagen type 1 cross-linked N-telopeptide, NTx)
    • treatment
      • operative fixation with intramedullary nail and stop bisphosphonates 
 

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Questions (39)
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(SAE07HK.46) A 62-year-old woman with a bone mass density (BMD) T-score of -2.0 sustained a subcapital fracture of her hip. She is an avid tennis player, and history reveals no previous fractures. What is the most appropriate follow-up care? Review Topic

QID: 6006
1

Antiresorptive bisphosphonate medication

73%

(30/41)

2

A repeat dual-energy x-ray absorptiometry scan (DEXA) and treatment if the T-score is less than -2.5

7%

(3/41)

3

A repeat DEXA scan and treatment if the T-score is greater than -1.5

2%

(1/41)

4

No treatment since the BMD is not in osteoporotic range

5%

(2/41)

5

(PTH) taraparatide hormone followed by surgery

2%

(1/41)

N/A

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(OBQ08.32) A 45 year-old woman who has not reached menopause yet falls from a standing height and sustains a distal radius fracture. A DEXA scan reveals a T-score of -2.2. Which of the following treatments is indicated in this patient? Review Topic

QID: 418
1

1,700 mg of calcium

21%

(369/1789)

2

1,200 mg of calcium

61%

(1087/1789)

3

1,700 mg of vitamin D

16%

(291/1789)

4

1,200 mg of iron

0%

(2/1789)

5

1,700 mg of PTH

2%

(37/1789)

ML 3

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PREFERRED RESPONSE 2
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(OBQ07.261) Which of the following is NOT included in the best management of a elderly female newly diagnosed with a fragility fracture? Review Topic

QID: 922
1

Hip and spine densitometry

2%

(7/435)

2

Laboratory analysis for secondary causes of osteoporosis

2%

(9/435)

3

Administration of calcium 1,500 mg/day

0%

(2/435)

4

Administration of Vitamin D 400 to 800 IU/day

1%

(6/435)

5

Low protein diet

94%

(409/435)

ML 1

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PREFERRED RESPONSE 5

(OBQ07.170) What effect does intermittent administration of parathyroid hormone have on bone? Review Topic

QID: 831
1

Anabolic

73%

(385/530)

2

Catabolic

20%

(106/530)

3

No effect

3%

(15/530)

4

Decreased quantity

2%

(8/530)

5

Decreased quality

3%

(14/530)

ML 2

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PREFERRED RESPONSE 1

(OBQ07.120) All of the following medications have been associated with an increased risk of osteoporosis EXCEPT: Review Topic

QID: 781
1

Selective serotonin reuptake inhibitors (SSRI)

19%

(82/436)

2

Glucocorticoids

1%

(4/436)

3

Non-steroidal anti-inflammatories (NSAIDs)

69%

(303/436)

4

Phenytoin

3%

(13/436)

5

Protease inhibitors

8%

(34/436)

ML 2

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PREFERRED RESPONSE 3

(OBQ09.165) Genetic polymorphisms in all of the following genes are associated with osteoporosis EXCEPT? Review Topic

QID: 2978
1

Calcitonin receptor

7%

(127/1893)

2

Estrogen receptor-1

2%

(32/1893)

3

Vitamin D receptor

2%

(44/1893)

4

Type I collagen alpha-1 chain

18%

(335/1893)

5

Cartilage oligomeric matrix protein (COMP)

71%

(1348/1893)

ML 3

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PREFERRED RESPONSE 5

(OBQ10.105) You are seeing a 13-year-old girl for asymptomatic flat feet and recommend observation. In educating this patient/family about general bone health, you recommend what amount of daily dietary calcium for your patient? Review Topic

QID: 3199
1

250mg - 500mg

1%

(19/1500)

2

500mg - 750mg

9%

(135/1500)

3

750mg - 1000mg

20%

(293/1500)

4

1000mg - 1500mg

66%

(994/1500)

5

over 1500mg per day

4%

(53/1500)

ML 3

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PREFERRED RESPONSE 4

(OBQ12.169) A 72-year-old woman presents with severe hip pain after stepping off of a curb. She denies any trauma or prior history of hip pain. Her past medical history is reviewed including a list of her current medications. Which of the following of her medications would place her at increased risk for a non-traumatic hip fracture? Review Topic

QID: 4529
1

Phenytoin

88%

(2913/3318)

2

Cephalexin

1%

(33/3318)

3

Simvastatin

4%

(127/3318)

4

Glipizide

3%

(114/3318)

5

Allopurinol

3%

(113/3318)

ML 1

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PREFERRED RESPONSE 1

(OBQ12.138) Which of the following pharmacologic treatments for osteoporosis has been associated with the potential risk for osteosarcoma development? Review Topic

QID: 4498
1

Ergocalciferol

5%

(127/2672)

2

Non-nitrogen containing bisphosphonate

4%

(94/2672)

3

Monoclonal Ig2 against RANKL

16%

(431/2672)

4

Nitrogen containing bisphosphonates

13%

(353/2672)

5

Recombinant parathyroid hormone (1-34)

61%

(1641/2672)

ML 3

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PREFERRED RESPONSE 5

(OBQ10.57) An 80 year-old female undergoes ORIF of her hip fracture without any complications. A hospitalist consult was obtained for medical clearance pre-operatively, and she was diagnosed with osteoporosis. Which of the following treatment scenarios will lead to the best management of the patient's osteoporosis? Review Topic

QID: 3145
1

Schedule a follow-up appointment with the patients primary care physician to initiate therapy

4%

(63/1563)

2

Order a physical therapy consult and initiate an exercise plan

1%

(16/1563)

3

Have the patient meet with a nutritionist to increase her calcium and vitamin D intake

2%

(30/1563)

4

Start bisphosphonates, and have the patient follow-up with her primary care physician

10%

(160/1563)

5

Perform a metabolic work-up as an inpatient, and set-up an appointment in an osteoporosis clinic

82%

(1288/1563)

ML 2

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PREFERRED RESPONSE 5

(OBQ08.96) With aging, there is a greater loss of mechanical strength in which of the following types of bone? Review Topic

QID: 482
1

Cortical bone more than trabecular bone

26%

(158/615)

2

Trabecular bone more than cortical bone

66%

(408/615)

3

Cortical bone and trabecular bone equally

6%

(39/615)

4

Only trabecular bone

1%

(6/615)

5

Only cortical bone

0%

(2/615)

ML 2

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PREFERRED RESPONSE 2

(OBQ06.178) Regarding bone densitometry, a T-score of -3.5 is defined as which of the following? Review Topic

QID: 364
1

Normal bone

0%

(0/520)

2

Osteopenia

2%

(10/520)

3

Age appropriate bone loss

0%

(2/520)

4

Osteoporosis

94%

(488/520)

5

None. One cannot make this diagnosis without further information.

3%

(18/520)

ML 1

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PREFERRED RESPONSE 4

(OBQ09.33) Risk factors for insufficiency fractures of the pelvic ring include all of the following EXCEPT: Review Topic

QID: 2846
1

Osteoporosis

0%

(2/739)

2

Corticosteroid treatment

1%

(8/739)

3

Total hip replacement with constrained liner

10%

(73/739)

4

Rheumatoid arthritis

6%

(44/739)

5

Total hip replacement with ceramic bearings

83%

(610/739)

ML 2

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PREFERRED RESPONSE 5

(OBQ11.115) A 58-year-old woman falls down while walking her dog and sustains the low-energy injury shown in Figures A and B. Which of the following lab values is most likely to be abnormal in this patient? Review Topic

QID: 3538
FIGURES:
1

Hydroxylproline

3%

(53/1656)

2

25-hydroxy cholecalciferol (25 OH vitamin D)

90%

(1493/1656)

3

Parathyroid hormone-related protein (PTHrP)

4%

(69/1656)

4

Sry-type high-mobility-group box transcription factor-9 (Sox-9)

1%

(16/1656)

5

LRP5 (low-density lipoprotein receptor-related protein)

1%

(19/1656)

ML 1

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PREFERRED RESPONSE 2

(OBQ11.257) A 55-year-old healthy female presents for a routine physical exam. In regards to bone health and osteoporosis prevention, what dose of calcium and vitamin D should be recommended for daily consumption? Review Topic

QID: 3680
1

1,500mg of calcium and 1,000 IUs of vitamin D

82%

(1380/1675)

2

2,200mg of calcium and 1,000 IUs of vitamin D

5%

(76/1675)

3

750mg of calcium and 5,000 IUs of vitamin D

8%

(132/1675)

4

750mg of calcium and 10,000 IUs of vitamin D

2%

(41/1675)

5

2,200mg of calcium and 5,000 IUs of vitamin D

2%

(38/1675)

ML 1

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PREFERRED RESPONSE 1

(OBQ10.231) Which of the following administered substances leads to net bone resorption? Review Topic

QID: 3330
1

Zoledronic acid (Reclast) injection once per year

5%

(113/2197)

2

Teriparatide (Forteo) injection once daily

9%

(188/2197)

3

Alendronate (Fosamax) oral once weekly

3%

(59/2197)

4

Teriparatide (Forteo) continuous infusion for 2 weeks

77%

(1695/2197)

5

Alendronate (Fosamax) oral once daily

6%

(132/2197)

ML 2

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PREFERRED RESPONSE 4

(OBQ11.36) A 52-year old woman who is not on any hormone replacement therapy (HRT) falls from standing height and sustains the injury seen in Figure A. Review of her medical history reveals that she carries a diagnosis of osteoporosis, and that her latest T-score was -3.0. How much calcium should she have been consuming on a daily basis prior to sustaining her injury? Review Topic

QID: 3459
FIGURES:
1

200-400mg

0%

(7/2175)

2

600-800mg

3%

(55/2175)

3

800-1000mg

7%

(148/2175)

4

1000-1500mg

73%

(1590/2175)

5

>1500mg

17%

(364/2175)

ML 2

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PREFERRED RESPONSE 4

(OBQ11.33) A 58-year-old female falls and sustains the injury shown in Figures A and B. Following surgical treatment of the fracture, which of the following is the most appropriate additional investigation? Review Topic

QID: 3456
FIGURES:
1

MRI of the pelvis

1%

(20/1520)

2

Urine electrophoresis

2%

(24/1520)

3

CT scan of the pelvis

2%

(29/1520)

4

Bone scan

3%

(43/1520)

5

DEXA scan

92%

(1396/1520)

ML 1

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PREFERRED RESPONSE 5

(OBQ07.158) A 63-year-old woman falls from standing and lands on her right hand. She complains of deformity and wrist pain. Radiographs are provided in Figure A. Following closed reduction, the patient inquires whether she has osteoporosis and if she is likely to have another fracture. In counselling the patient, which of the following is the strongest predictor for a future fracture from low energy trauma? Review Topic

QID: 819
FIGURES:
1

Bone mineral density T-score < -2.5

5%

(84/1645)

2

Low vitamin D levels

0%

(7/1645)

3

Family history of osteoporosis

0%

(4/1645)

4

History of a prior fragility fracture

94%

(1540/1645)

5

Ten year history of oral prednisone use

1%

(9/1645)

ML 1

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PREFERRED RESPONSE 4

(OBQ06.58) Which of the following patients are at greatest risk of having a future vertebral fragility fracture? Review Topic

QID: 169
1

Elderly female with prior hip fragility fracture

8%

(97/1223)

2

Elderly female with prior distal radius fragility fracture

6%

(74/1223)

3

Elderly female with prior T6 compression fragility fracture

79%

(967/1223)

4

Elderly female with a T-score of -3.0

6%

(74/1223)

5

Elderly female currently on hormone replacement therapy

0%

(3/1223)

ML 2

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(OBQ10.119) Which of the following medications is a recombinant form of parathyroid hormone that has been found to stimulate new bone formation in patients with postmenopausal osteoporosis? Review Topic

QID: 3213
1

Risedronate (Actonel)

1%

(31/2691)

2

Zoledronic acid (Reclast)

4%

(109/2691)

3

Teriparatide (Forteo)

91%

(2450/2691)

4

Ibandronate (Boniva)

1%

(40/2691)

5

Alendronate (Fosamax)

2%

(48/2691)

ML 1

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