Business of Orthopedics
Daniel J Acevedo, PA-C, is a nationally certified physician assistant and the lead advanced practice provider at OrthoVirginia in Lynchburg, Virginia. His interests include physician assistant education and osteoporosis.
A 75-year-old woman presents today for a preoperative evaluation prior to a left total knee replacement. She is a thin, otherwise healthy, white woman with no significant medical history aside from hypertension managed by a low-dose diuretic, diet and exercise. She does note in passing that she has gotten shorter over the years. She entered early menopause at the age of 40 years due to a total hysterectomy and was not treated with hormone replacement therapy. She does not drink or smoke. Her mother died at age 90 years, 8 months after surgery for a broken hip. You ask the patient if she has ever had a bone density test, or DXA scan, and she states that she has not.
In the last installment in this series, we learned how to define osteoporosis, the scope of the problem and how to easily recognize a fragility fracture. Osteoporosis is a systemic disease characterized by low bone mass and micro architectural deterioration of bone tissue which increases the risk of fractures. Osteoporosis and its concomitant fractures are common, expensive and contribute to a decreased quality of life. A fragility fracture is any type of fracture that results from a low energy trauma and is likely due to osteoporosis.
There are many ways physician assistants can become involved in osteoporosis care. Prevention of the progression of osteoporosis and early recognition of low bone mass is paramount. This is a fantastic avenue for clinical support by advanced practice providers, such as physician assistants and nurse practitioners. Recognition begins with understanding who is at risk for osteoporosis. Age and sex are the two greatest non-modifiable risk factors for osteoporosis.
Most patients with osteoporosis are postmenopausal white women. However, any postmenopausal woman is at risk for osteoporosis. In fact, it is estimated that one in two women older than 50 years of age will suffer a low energy fracture and while Caucasian women are most commonly represented, postmenopausal women of all races are affected by osteoporosis. This is due to estrogens potent anabolic effects on bone metabolism. Early menopause either naturally or surgically with a hysterectomy with removal of the ovaries will decrease estrogens effects on bone and increase the chance of low bone mass.
One more important non-modifiable risk factor for osteoporosis and future low energy fractures includes familial history of hip fracture. A high index of suspicion should remain in any adult patient older than 50 years of age with a positive paternal or maternal history of hip fracture. This alone can prompt you to ask more questions about bone health and possibly indicate the patient for a bone density test
Next, personal habits can have a tremendous effect on osteoporosis and bone health. Tobacco users independent of the dose and quality are at increased risk of low bone mass and osteoporosis. These patients are also at risk for developing COPD, which is commonly treated by steroids which affect bone metabolism. Those who drink alcohol, especially those who drink three or more alcoholic drinks per day, are at increased risk as well. Finally, low BMI also increases the chance of fracture due to osteoporosis.
Finally, medical comorbidities that are common to advanced practice providers in all specialties can increase the risk of fragility fractures. Inflammatory diseases, such as rheumatoid arthritis and lupus; diseases of malabsorption, such as celiac disease; and endocrine diseases, such as hyperparathyroidism, hypothyroidism and diabetes mellitus; are all associated with low bone mass and osteoporosis. Common medications including those for management of seizures, depression and GERD also raise a patient's risks.
While this list of modifiable and non-modifiable risk factors is not exhaustive and tells only a part of the story, it is certainly high yield and can be utilized in any patient encounter so as to recognize and possibly treat bone health. These questions and clinical knowledge have greatly influenced my clinical intuition for those at risk for low bone mass and osteoporosis.
In the next blog, we will delve into diagnostic modalities including DXA, FRAX, quantitative CT and trabecular bone score.
Daniel J. Acevedo, PA-C, is a nationally certified physician assistant and the lead advanced practice provider at OrthoVirginia in Lynchburg, Virginia. His interests include physician assistant education and osteoporosis.
Disclosure: Acevedo reports no relevant financial disclosures.
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