HOME        REFERRAL         GP ASSESSMENT        ULTRASOUND          CAUSES OF OSTEOPOROSIS   

  GUIDELINES  FOR PREVENTION & TREATMENT            BACKGROUND             RESEARCH

THE GP’S ASSESSMENT PRIOR TO REFERRAL

As usual, assessment involves taking the relevant history, performing a relevant examination and requesting relevant blood tests and, if necessary, X rays.

HISTORY    Here it is important to identify  the clinical risk factors associated with osteoporosis, i.e. low bone density. These are reflected in the referral form. Fall related factors are also important in predicting fracture and in the elderly patient, if protective reflexes are impaired sufficiently, then impact forces are sufficient to fracture even normal bone. When faced with a patient who has recently had a fracture from a standing height or less, i.e. low impact, it is sometimes difficult to know whether the fracture occurred due to over-stressing normal bone in a badly cushioned fall, or whether it occurred due to the bone being intrinsically weak, i.e. osteoporotic. In such a context osteoporosis scanning can help as it will identify weak bone. Thus sometimes fractures – even at typically osteoporotic sites i.e. wrist and hip – are not due to osteoporosis. Patients with a history of recurrent falls need assistance in fall prevention, i.e. walking aids, rails, OT assessment, a review of drug history, etc.

EXAMINATION    Here knowledge of body mass index is important (weight in kgs divided by height in metres squared). The presence of a kyphosis – usually thoracic – is important. Thoracic kyphosis is not always due to osteoporosis,  it can be due to degenerative disc disease. To distinguish between the two a lateral thoracic x ray is required. Some assessment as to the degree of thoracic kyphosis is useful, e.g. the occiput wall distance measured in centimetres. An assessment of balance is useful, e.g.. heel-toe test or by asking the patient to close the eyes and checking for gentle sway or loss of balance induced by gentle short pushes.

 INVESTIGATIONS

Haematology – FBC, ESR..

Biochemistry – U’s & E’s, LFT’s, TFT’s, calcium and phosphate.

If the ESR is raised – serum protein, electrophoresis and urinary Bence Jones protein (spot urine). The serum calcium level in osteoporosis is usually normal.

Also useful occasionally – 25-hydroxy vit.D (15-100). Any vit. D level less than 60 - 70 is sub-optimal and the patient would benefit from vit. D supplementation.

Testosterone – a serum testosterone level less than 10 with clinical symptoms of hypogonadism may warrant investigation and replacement.

FSH – useful if there is doubt whether the patient is menopausal.

X Rays . Osteopenia on an  X Ray hints at osteoporosis although it is not always a reliable guide as it relies on subjective assessment. An osteoporotic fracture of a thoracic vertebra results in a loss of anterior height or occasionally mid-vertebral height (called a bi-concave vertebral deformity), or very occasionally posterior height. Loss of this height to greater than or equal to 75% of the height of the rest of the vertebra is the conventional way of diagnosing vertebral deformity.

Other causes of vertebral deformity include trauma sustained from a badly cushioned fall, osteomalacia, Scheuermann’s (anterior wedging due to adolescent vertebral end plate growth anomaly). Neoplasm, e.g. bony secondaries or myeloma.