OSTEOPOROTIC

HIP FRACTURE
Pre-Clinical Students Peer Group I
Faculty of Medicine, Sriwijaya University
December 2018

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SKDI

 OSTEOPOROSIS 3A (NOT EMERGENCY)

 HIP FRACTURE 3B (EMERGENCY)

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Definition

 Osteoporosis is a generalized skeletal disorder characterized by low bone

mass and micro-architectural deterioration of bone which leads to fragility
and risk of fracture.
 The World Health Organization (WHO) criteria for osteoporosis are met when
bone mineral density (BMD) falls 2.5 standard deviations below the mean
found in young adult women.

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Prevalence

Chart 1.
Osteoporosis prevalence in Indonesia based on sex

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Prevalence

Chart 2.
Bone mineral density of male spine and femur neck
in Indonesia
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Causes

 Reduced BMD may be caused by a range of factors such as:

 Endocrine disturbances,
 Dietary deficiencies, or
 Side effects of pharmacological interventions.

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Risk Factors

 Modified
 Lack of physical activity
 Lack of calcium uptake and vitamin D
 Protein deficiency
 Lack of sun exposure (UVB)
 Smoking
 Hormonal (estrogen)
 Drug usage (steroid, heparin, cyclosporine)

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Risk Factors

 Non-Modified
 Heredity
 Sex (most in female)
 Age
 Race (Asian, Caucasian)
 Menopause
 Body size

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Clinical Manifest

 Classic symptom: back pain (usually triggered by physical stress)

 Also can be described with bone fracture, decreased of body height, and
kyphosis
 Fracture (most: hip fracture)

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Pain in Osteoporosis

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Molecular Mechanism of Pain in
Osteoporosis

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Diagnosis

LABORATORY
ANAMNESIS DENSITOMETER
EXAMINATION

PHYSICAL
IMAGING
EXAMINATION

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Anamnesis

 There are predisposition (risk) factors?

 Suddenly fracture? Trauma?
 Pain? with restricted movement?
 Decreased of Body Height or Kyphosis?
 One minute risk test form released by IOF can be used for osteoporosis
(presented in next slide)

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Picture 1.
One minute test form to
evaluates risk of osteoporosis

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Physical Examination

 Observe body height and body posture

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Laboratory Examination

 Calcium, Phosphate, Alkaline Phosphatase

 When indicated, do the examination of thyroid, liver, and kidney function
 Measurement of 24 h urinary calcium excretion
 Check the level of parathyroid hormone (hyperparathyroidism)
 Check the level of 25 OH-D (mal-absorption)

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Imaging

 It’s clear when there’s an advanced osteoporosis or if BMD result indicates

highly positive

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Densitometer Examination

 Ultrasound densitometer is the best diagnostic tool for osteopenia and

osteoporosis, but it can’t determine the progress of loss of bone mass
 If ultrasound densitometer shows: (T-score < -2,5)  use DEXA!
 DEXA or Dual Energy X-Ray Absorptiometry is used for measure bone strength
or mineral bone density.

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 Treatment

Chart 3.
Treatment Algorithm
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(Indonesian Ministry of Health)
Treatment (Medicamentosa)

 Hormonal
 Estrogen (carefully, must be given by expert)
 Kombinasi estrogen dan progesterone
 Testosterone
 Steroid anabolik
 Non-hormonal
 Kalsitonin
 Bifosfonat
 Kalsium
 Vitamin D
 Fitoesterogen
 Tiasid 12/12/2018 20
Consequence

 One consequence of osteoporosis is hip fracture which may also be attributed

to extra-skeletal factors such as frailty, failing eyesight, and a tendency to
fall.

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Hip Fracture

• Hip fracture: fracture occurring in the area

between the edge of the femoral head and 5
cm below the lesser trochanter.
• Types: intra-capsular (includes sub-capital or
femoral neck fractures), trochanteric and sub-
trochanteric fractures.
• Not exclusively a surgical concern: a
multidisciplinary approach is required for
management

Picture 2. 12/12/2018 22
Classification of hip fractures
Hip (Femoral Neck)

 Lateral epiphyseal artery

 Terminal branch medial circumflex
femoral artery
 Predominant blood supply to weight
bearing dome of head
 After fracture, blood supply depends
on retinacular vessels
 Greater fracture displacement causes
greater risk of retinacular vessels
disruption
Picture 3.
 Tamponade effect of blood will intact Vascularization of femoral neck
with capsule
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Pain caused by fracture

 Bone fracture healing consists of a series of overlapping events: in•flammation

soft callus formation, hard callus formation and remodeling (Soames 1995).
During the in•flammatory phase, hyperalgesia and pain may well be related to
released cytokines, prostanoids, histamine and bradykinin.
 It has been suggested that pain is caused either by stretching of nerve endings
in the periosteum or by micro-fractures in the fragile bone in the spurs.
 Microfractures at the origin or insertion of a muscle in the lower extremity
have also been found to cause pain which gets worse with physical activity
 During the inflammatory response to fracture, several mediators are released
and will putatively activate and sensitize primary sensory neurons, in parallel,
intense nerve sprouting that occurs in the fracture callus area is also
suggested to be involved in pain signaling. The establishment of hyperalgesia
and allodynia after fracture indicates the development of peripheral and
central sensitization, still, the underlying mechanisms are largely unknown
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Avoid Extra-skeletal Risk Factor for Hip
Fracture!
 Intrinsic
 Balance, gait, mobility problems
 Medication (sedative, anti-HT), alcohol
 Visual and/or cognitive impairment
 Postural hypotension
 Extrinsic
 Poor lighting
 Steep stairs
 Slippery floors
 Badly fitting footwear

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Osteoporosis Preventions Based on
Rehabilitation Department
 Primary
 To prevent populations with not at risk; Calcium, Vitamin D, and UVB rays
 Calcium (1200 mg divided in two doses per day), Vitamin D (>1500 IU)
 Secondary
 To prevent the risky populations; BMD monitoring, more dietary intake, more
exposure of UVB rays
 Tertiary
 To prevent the complication in osteoporosis patients; falls prevention, avoid extra-
skeletal risk factor which presented in previous slide
 Quaternary
 To prevent morbidity in osteoporotic fracture patients; medical therapy,
rehabilitation! 12/12/2018 26
Exercise and Rehabilitation

 Improve strength, endurance, flexibility, and posture

 Maintain bone density
 Prevent falls
 30 minute moderate intensity daily
 Post-fracture rehab may reduce future fracture

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Strategy of Health Promotion

 Goal: eliminate modifiable risk factors

 Screening is not common..?
 Targeted populations: “at risk”
 Weight bearing exercise and dietary intake
 Falls prevention

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THE END
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Conceptual Framework

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