Osteoporosis

Osteoporosis is a decrease in bone strength. The strength of the bone depends on mineral density and bone quality. Osteoporotic bone is at risk of fracture at the hip, wrist and spine.

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If fracture of the vertebral spine occurs, the patient will have a fivefold increased risk for having a second vertebral fracture or hip fracture. A second vertebral fracture means you may have more compression fractures in the future.

With one hip fracture, there will be a tenfold increase of another hip fracture occurring. Men with hip fractures have a higher mortality rate than women.

Lifetime risk of fractures of the hip, spine and wrist is 40 %. The decrease of bone strength and bone mass clearly predicts fracture risk.

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Osteoporosis affects 45% of women aged 50 or older. There is some correlation between osteoporotic fracture and risk of death. This is logical since 25% of patients with hip fracture die within one year. The lifetime risk is high with senile osteoporosis. There are about million osteoporosis related fractures that occur per year.

Men and women both begin to start “spending” or losing bone at a certain point in their lives. Banking or building up of bone during youth has benefits during the later years. Most individuals obtain their peak bone mass between ages of 16 and 25 years. Men begin to lose bone mass after the age of 25 years at a rate of 0.3% per year. Women begin to lose bone at a rate of 0.5% per year. After menopause there is an accelerated rate of bone loss at the rate of 2-3% of total bone loss per year for about 10 years.

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Osteoporosis has bone mineralization but abnormal osteoclast function. There are two types of osteoporosis:

  1. Type I: postmenopausal which occurs 15-20 years after menopause. It has increased risk of vertebral and wrist fractures. It is due to estrogen deficiency.
  2. Type II: senile which occurs in men and women over the age of 70 years. Vertebral and hip fractures are a risk. It occurs more in females than males with a ratio 2:1. It is due to aging and long term calcium deficiency.

20-25% of elderly patients could die within one year suffering of a hip fracture.

osteoporosis4.pngRisk factors for osteoporosis include: thin, north European descent, people who live sedentary lifestyles, smoker and drinkers, and anti-seizure medications as phenytoin (Dilantin) and phenobarbital.

The bone mineral density is measured by T- score which is relative to normal age, young, matched control (25 year old women) and Z-score which is relative to similar aged patients.

How is osteoporosis measured? It is measured by DEXA scan at the hip through the T –score. DEXA scan is important in predicting fracture risk.osteoporosis5.png

Lab findings as albumin, calcium, phosphate, vitamin D, parathyroid hormone and bone specific alkaline phosphatase are usually normal.

Vitamin D levels are low in about 70 % of patients with fracture. Vitamin D absorbs calcium from the intestines. With aging, the stomach acidity decreases and the calcium absorption decreases and vitamin D requirements increase. Elderly need more vitamins D to absorb the same amount of calcium.

Treatment of osteoporosis include: bisphosphonates, Denosumab and calcitonin. Bone stimulation can be achieved by parathyroid hormone, calcium and vitamin D.

When to initiate therapy? If T-score is less than -2 with no risk factors, if T-score is less than -1.5 with at least one risk factor as prior vertebral fracture or hip fracture.

What decides if you develop osteoporosis or not? Your savings: you can control this by adding more bone when you are young before the age of 25 years. You begin spending your bone after 25 years.

Heat Illness in Athletes

As summer approaches, athletes, coaches and other individuals will need to be aware of heat-related illnesses. Heat illnesses include a spectrum of conditions ranging from heat syncope, heat cramps and heat exhaustion to the more severe heat stroke.

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Heat Syncope (fainting) is a form of orthostatic hypotension that is related to dehydration. It occurs due to inadequate cardiac output and hypotension. It also occurs with standing quickly after sitting or lying down for prolonged durations in the heat. Symptoms include fainting, dizziness and light-headedness. Treatment includes oral rehydration (water, juice or sports drinks) and placing the patient flat on the ground in a cool area with slight elevation of the legs to push the blood back to the vital organs such as the brain.

Heat Cramps are painful muscle cramps that occur due to decreased sodium heat2.pngconcentration in the blood. The patient’s core temperature is usually not elevated. Sodium may decrease when salts are lost in sweat or with excessive water intake that does not include electrolytes leading to a situation called dilutional hyponatremia. Symptoms include painful muscle cramps occurring commonly in the abdominal muscles, arms, legs and thighs. Treatment includes rest, cooling and IV fluids or oral rehydration with fluids rich in electrolytes (sports drinks and juices) to replenish the sodium stores. Prevention could be achieved by consumption of fluids high in electrolytes before strenuous activities.

heat3Heat Exhaustion is the most common heat illness. The body temperature becomes elevated but is less than 40°C. The core body temperature is best measured rectally. The signs and symptoms of heat exhaustion include profuse sweating, core body temperature lower than 40°C, weakness and fatigue, cramping, headaches, nausea and vomiting,  fainting, hypotension, increased heart rate, and fast shallow breathing. Treatment includes rest, IV fluids or oral rehydration and rapid cooling by whole-body immersion in an ice bath.

Heat Stroke is the most severe form of heat illness. It is a medical emergency that needs immediate attention. The patient should be transported to the hospital as soon as possible. Heat strokes occur due to failure of the body’s normal thermoregulatory mechanism. If treatment is not started promptly, end-organ failure and ultimately death may occur. Heat strokes have a high mortality rate and require quick reduction of the patient’s temperature. The three characteristic features of this condition are a lack of sweating, core body temperature above 40°C (best measured rectally) and an altered mental status. Additional signs and symptoms include hot, dry skin, disorientation, confusion and hallucinations, headache and slurred speech. This is a serious medical emergency that requires rapid core body temperature reduction. The patient should have close monitoring of airway, breathing and circulation. The physician should implement basic life support and ACLS protocols. Rapid cooling by whole-body immersion in an ice bath will be utilized as well as IV fluids.

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What is Brachial Neuritis?

Brachial Neuritis is a condition of severe shoulder pain that usually radiates dowbrachial1n the arm and up to the neck and scapula. It can also be referred to as neuralgic amyotrophy (NA) and/or parsonage-turner syndrome. The pain is sudden, severe and may last for a few weeks. This pain may disturb sleep! It usually occurs on its own without a history of trauma. The condition occurs more in males and it may occur at any age.

The position of comfort is the shoulder adducted with the elbow flexed. Neck movement and Valsalva’s maneuver do not increase the pain. Pain is increased by movement of the arm. Although the pain is severe and sudden, lasting at least a few weeks, the condition is usually under diagnosed or not diagnosed at all.

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Weakness may be absent in the acute phase, however as the pain resolves, weakness of certain muscles will remain. The degree of weakness correlates with the severity of the initial pain.

brachial3The muscles that are commonly involved are the supraspinatus and the infraspinatus muscles. The suprascapular nerve is the most commonly involved followed by the deltoid, which is the abductor of the s shoulder innervated by the axillary nerve.

The condition may occur bilaterally and may occur subclinically (only seen on an EMG). Muscle weakness may continue for a significant period of time. Sensory changes may be variable. If there is no sensory loss, this is a classic finding that confirms the diagnosis. There is a decreased sensation in a lot of cases. The lateral antebrachial cutaneous nerve is usually involved.

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Motor changes predominantly occur over sensory changes and can involve the brachial plexus from C5-T1 with a variable degree of weakness. It can affect more than one nerve branch with certain patterns of involvement can be seen on the MRI.

It is a benign, self-limiting problem with 90% of patients returning to near normal condition in about 3 years. Only about 1/3 of the patients will recover at about 1 year. The etiology of brachial plexus neuritis is unknown.

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Hyperintense muscles involved in the sagittal plane (supraspinatus, infraspinatus, and deltoid). In advanced cases, the muscles will either be atrophied or have fatty infiltration.

EMG and Nerve studies are helpful for the diagnosis and the prognosis. In the first 4 weeks, there will be acute denervation in the roots and the peripheral nerves. EMG may be abnormal for up to 7 years after the diagnosis.

Rule out other conditions such as radiculopathy from a herniated disc. This can bebrachial6 excluded from imaging of the cervical spine. Other conditions that may be considered differential diagnoses are adhesive capsulitis and lyme disease. There are two particular conditions that are very interesting with acute brachial neuritis. The first is bilateral interosseous nerve palsy, which is caused by viral brachial neuritis. The patient has the inability to do the Ok sign. It is motor loss that follows intense shoulder pain and usually the condition resolves with time.

The second condition is winging of the scapula. The serratus anterior muscle involvement may cause dull aches and pain. Acute, sudden severe pain consider with acute brachial neuritis that involves the C7 nerve root. C7 nerve root gives the long thoracic nerve, which innervates the serratus anterior muscle. If the patient has severe shoulder pain and winging of the scapular rule out brachial neuritis!

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The treatment includes rest, observation and steroid injections. Avoid using a sling, a sling will cause flexion and internal rotation contracture of the shoulder. The sling may also cause a stiff elbow.