Bone Densitometry

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Bone Composition
45-70% inorganic
Calcium, phosphorus, magnesium crystalline form of apatite Ca10(PO4)(OH2)

25-30% organic
collagen cellular elements

5-25% water
SEM of the Hydroxyapatite Crystal

General Structure of Bone

Cortex:
Cortex outer portion, compact bone covered by periosteum Periosteum Trabeculae: inner portion of spongy bone containing the blood forming elements (myeloid) or fatty marrow

Marrow

Periosteal membrane

Bone Metabolic Response

The combination of cortical bone together with spongy trabecular bone provides both structural strength and an extended surface, on which rapid changes in bone formation or resorption can respond to fluctuating metabolic needs. The metabolic responses of the skeleton mainly occur on trabecular bone surfaces.

Aging and bone loss

Bone loss might be seen in aged people and postmenopausal women. Bone loss affects trabecular bone. Although the entire skeleton loses bone mass with aging, the distribution of bone loss is not uniform because of the different proportions of trabecular and cortical bone in the various parts of skeleton.

Osteopenia and Osteoporosis

Osteopenia refers to any condition involving reduced bone mass. Osteoporosis, a form of osteopenia, is decreased bone mass with normal bone mineralization.

Causes of Osteoporosis
Primary (95%): occurs mainly in postmenopausal women and the elderly (above 50 years old men). Secondary (5%): to long-term steroids, chronic renal failure, rheumatoid arthritis and hyperparathyroidism.

Bone Density

Fractures
The most common osteoporotic-related fractures are those involving: 1-Spine (thoracic and lumbar vertebral bodies). 2-Femur (the neck and intertrochanteric regions). 3-Wrist (distal radius).

Risk Sites
Femoral neck Vertebral bodies Distal radius

Bone Mass and Bone Density

Bone Mass indicates the amount of mineralized tissue in bone. Bone Density indicates the mass of bone defined either by length (g/cm), area (g/cm2) or volume (g/cm3). Bone mass measurements are currently considered to be the most valuable objective indicator of fracture risk.

High Risk Patients

Bone mass is an important determinant of fractures, and hence bone mass measurements may help reduce the number of fractures by identifying high risk patients, who can then receive effective prophylaxis.

Measurement Technique
Dual Energy X-ray (DEXA)

Dual Energy X-ray

DEXA
DEXA stands for dual-energy X-ray absorptiometry. DEXA utilizes an x-ray tube as the radiation source.

Scanned Areas
DEXA equipment allows scanning of the spine and hip which are the most frequent sites for fractures.

WHO
World Health Organization study group has established a clinical definition for osteoporosis based on a BMD (bone mineral density) measurement of the spine, hip or forearm expressed in standard deviation (SD) units called Tscores.

T-score, cont..
T-score indicates the difference between the patients measured BMD and the ideal peak bone mass achieved by a young adult. WHO has the following definitions according to T-score value.

Osteoporosis
In WHO report, if T-score is < -2.5 at the spine, hip, or forearm; the patient is classified as having osteoporosis. This patient has high risk for fracture.

Osteopenia
In WHO report, if T-score is between -2.5 and -1 at the spine, hip, or forearm; the patient is classified as having osteopenia. This patient has intermediate risk for fracture.

Normal
In WHO report, if T-score is > -1 the patient is classified as normal. This patient has low risk for fracture.

Z-scores
Z-score indicates the difference between the patients measured BMD and the ideal peak bone mass achieved by agedmatched peers. Z-score can not be used to diagnose osteoporosis.

Standard Deviation (T-score)

s=
Standard Deviation

(Xi - X)
n-1

Normal Distribution
400 350 300 250 200 150 100 50 0

Normal Distribution
400 350 300 250 200 150 100 50 0
2 SD 1 SD Mean

Number of Observations

Defined by an Average or mean and a Standard Deviation

Conclusion
Bone densitometry provide a measure of fracture risk that is analogous to assessment of blood pressure with regard to the risk of stroke or to measurement of cholesterol with regard to the risk of developing ischemic heart disease.