Osteoporosis & Fractures: Symptoms, Causes & Orthopaedic Treatment in Malaysia

What is Osteoporosis?

Osteoporosis is a bone disease that develops when bone mineral density and bone mass decrease. This can lead to decreased bone strength, increasing the risk of fractures. Osteoporosis can progress over time, causing the bone to become more porous (weak) and break more easily. When viewed microscopically, healthy bone looks like a honeycomb. In cases of osteoporosis, the holes and spaces in the honeycomb are much bigger than those found in healthy bone.

Women and older adults are more at risk for developing osteoporosis. Heredity, low body weight, smoking, and chronic use of certain medications (such as steroids) are also risk factors for the disease.

Lifting, bending, bumping into furniture, and even sneezing can cause a bone to break in people affected by osteoporosis. Fractures of the hip, spine, or wrist are most common, but other bones are also susceptible to breaks.

As an orthopaedic surgeon in Kuala Lumpur, Malaysia, I frequently encounter elderly patients with low-impact fractures such as wrist, hip, and even spine fractures with undiagnosed and untreated osteoporosis. An orthopaedic surgeon plays a critical role in the management and treatment of osteoporosis-related fractures. The role of the orthopaedic surgeon in these cases involves both surgical and non-surgical interventions, as well as preventive measures to reduce the risk of future fractures.

What Are the Symptoms?

Osteoporosis is a “silent disease” because it usually develops without noticeable symptoms until a fracture occurs. However, some signs and symptoms may indicate the presence of osteoporosis or its effects:

Fractures

Common Areas: The most frequent fractures occur in the wrist, hip, and spine.

Low-Impact Fractures: Fractures from minimal trauma, such as bending over, coughing, or a minor fall, are a common sign.

Back Pain

Sudden or Gradual: Often caused by a fractured or collapsed vertebra. This pain can be sudden and severe, or it may develop gradually over time.

Loss of Height

Noticeable Decrease: A noticeable decrease in height over time, often due to vertebral compression fractures.

Stooped Posture (Kyphosis)

Forward-Curving Spine: A forward-curving spine, often called a “dowager’s hump,” results from vertebral fractures.

Weakness or Fragility

General Feeling: A general feeling of weakness or frailty, especially in older adults, may be related to osteoporosis.

Limited Mobility

Daily Activities: Difficulty in performing daily activities due to pain or fractures, particularly after a hip or spinal fracture.

Since osteoporosis often progresses without symptoms, regular screening and monitoring, especially in high-risk groups, are important for early detection and treatment.

Who is Commonly Affected?

Osteoporosis primarily affects older adults, particularly women.

Postmenopausal Women

Higher Risk: Women are at a higher risk due to the rapid decrease in oestrogen levels after menopause, which accelerates bone loss.

Elderly Men

Age-Related Risk: Although men experience a slower rate of bone loss than women, they are still at risk, especially after age 70 when bone density naturally decreases.

People with Family History

Genetic Predisposition: A genetic predisposition can increase the risk, particularly if close family members have had osteoporosis or fractures.

Individuals with Certain Medical Conditions

Increased Risk: Conditions like rheumatoid arthritis, coeliac disease, and hyperthyroidism can increase the risk.

People with Lifestyle Risk Factors

Contributing Factors: Smoking, excessive alcohol consumption, a sedentary lifestyle, and a diet low in calcium and vitamin D can contribute to the development of osteoporosis.

Long-Term Use of Certain Medications

Medications: Medications like corticosteroids, some anticonvulsants, and certain cancer treatments can lead to bone loss and increase the risk of osteoporosis.

How to Diagnose Osteoporosis?

A diagnosis of osteoporosis is usually made only after a low-trauma fracture (fall from standing height or lower) as most patients tend to be asymptomatic. Common fracture sites due to osteoporosis are the hip, spine, and forearm. Other clinical presentations include increasing dorsal kyphosis (Dowager’s hump), historical height loss of 4 cm or more (1.5 inches or more), and acute back pain following seemingly innocuous activities (such as bending, lifting objects, coughing, or sneezing).

Osteoporosis is typically diagnosed through a combination of medical history, physical examination, and specific tests. Here are the key methods:

Bone Mineral Density (BMD) Test

BMD or Dual-Energy X-ray Absorptiometry (DEXA or DXA) Scan: This is the most common and accurate method. A DXA scan uses X-ray beams at two different energies to calculate bone density. It measures bone density at the hip and spine, and then your BMD is compared to two norms—healthy young adults (your T-score) and age-matched adults (your Z-score).

Uses of the DXA Scan:

• Confirm a diagnosis of osteoporosis if you have already had a bone fracture.
• Predict your chances of fracturing a bone in the future.
• Determine your rate of bone loss.
• See if treatment is working.

The DXA machine converts bone density information to your T-score and Z-score. The T-score measures the amount of bone you have in comparison to a normal population of younger people and is used to estimate your risk of developing a fracture and the need for drug therapy. Positive T-scores indicate the bone is stronger than normal; negative T-scores indicate the bone is weaker than normal. This classification does not apply to premenopausal women, men under 50 years old, and children.

T-score Interpretation:

• Normal: T-score of -1.0 or above.
• Osteopenia (low bone mass): T-score between -1.0 and -2.5.
• Osteoporosis: T-score of -2.5 or below.

Osteoporosis is diagnosed based on a T-score of -2.5 or lower on bone mineral density (BMD) measurement by dual-energy X-ray absorptiometry (DXA) at the femoral neck or lumbar spine. Notably, a clinical diagnosis of osteoporosis can be made after a low-trauma spine or hip fracture, irrespective of BMD measurements. Note that if you have previously had a low-trauma bone fracture, you are also classified as having osteoporosis and need to take osteoporosis medications, regardless of your bone density T-score.

Osteoporosis anywhere in your body is Osteoporosis everywhere: The diagnosis is made using the lowest T-score. For example, if the T-score in your spine is -2.7 and the T-score in your hip is -2.2, the diagnosis is osteoporosis. It is incorrect to say there is osteoporosis in the spine and osteopenia in the hip.

For people with low bone density, the FRAX (Fracture Risk Assessment) tool is often included in the report. Using femoral neck bone density (the bone density of a portion of the femur) and patient-specific data, the 10-year probability of a major osteoporotic fracture and a hip fracture is generated.

Fracture Risk Assessment (FRAX)

Online Calculator Tool: This tool estimates the 10-year probability of a fracture based on bone density and other risk factors, such as age, gender, family history, smoking, and alcohol use.

X-rays

Fractures or Bone Loss: X-rays can show fractures or bone loss (osteopenia), but they are less sensitive than a DEXA scan for detecting early osteoporosis. Routine plain X-rays are not recommended as radiological osteopenia is apparent in plain X-rays only after more than 30% of bone loss has occurred.

Laboratory Tests

Blood and Urine Tests: These may be done to rule out other conditions that could cause bone loss or fractures, such as thyroid problems or vitamin D deficiency.

Physical Examination

Posture and Height Check: A healthcare provider may assess posture, check for height loss, and look for signs of fractures, particularly in the spine. Early diagnosis through these methods is crucial for managing osteoporosis and preventing fractures.

Who Should Be Screened and Diagnosed?

In Malaysia, osteoporosis screening is recommended for specific groups who are at higher risk of developing the condition. Here are the key groups that should consider screening:

Postmenopausal Women Over 50 Years Old

Clinical Guidelines: The Malaysian Clinical Practice Guidelines (2022) recommend screening for osteoporosis in individuals with prior low-trauma fractures, those with clinical risk factors, secondary osteoporosis, height loss and falls risk, and for all postmenopausal women aged 50 years and above.

Men Aged 70 and Above

Age Consideration: Men aged 70 and above should consider screening due to the natural decrease in bone density with age.

Individuals with a History of Fractures

Low-Impact Fractures: Adults who have experienced a fracture after the age of 50, particularly those with low-impact fractures, should be screened.

People with Risk Factors

Family History and Medical Conditions: Those with a family history of osteoporosis or fractures, and individuals with medical conditions associated with bone loss, such as rheumatoid arthritis, hyperthyroidism, or coeliac disease, should be screened.

People with Lifestyle Risk Factors

Contributing Factors: Smokers, heavy alcohol users, or individuals with a sedentary lifestyle should be screened. Those with a diet low in calcium and vitamin D are also at risk.

Individuals with Low Body Weight

BMI Consideration: People with a body mass index (BMI) less than 19 kg/m² are at higher risk and should be considered for screening.

Women with Early Menopause or Oophorectomy

Increased Risk: Women who experienced menopause before age 45 or had both ovaries removed are at increased risk and should be screened.

Patients with Chronic Conditions

Chronic Diseases: Those with chronic diseases like chronic kidney disease or inflammatory bowel disease, which can lead to bone loss, should also be screened.

Is Osteoporosis a Serious Condition?

Osteoporosis is linked to increased morbidity and mortality, particularly due to the fractures it causes. Hip fractures are associated with high morbidity and a mortality rate of up to 20% in the first year. The majority of those who survive are disabled, and only 25% will resume normal activities. The Asian Federation of Osteoporosis Societies study estimated that the number of hip fractures in Malaysia would increase from 5,880 in 2018 to 20,893 in 2050.

Increased Morbidity

Fractures: Osteoporosis weakens bones, making them more susceptible to fractures, especially in the hip, spine, and wrist. Hip fractures, in particular, are a major cause of disability.

Loss of Mobility: Fractures often lead to reduced mobility, requiring long-term rehabilitation and potentially resulting in permanent disability.

Chronic Pain: Spinal fractures, which can occur due to osteoporosis, often lead to chronic back pain, height loss, and spinal deformities (kyphosis or “dowager’s hump”).

Dependence: Many individuals who suffer from osteoporotic fractures lose their independence, requiring assistance with daily activities or long-term care.

Increased Mortality

Hip Fractures: These are particularly serious, with significant mortality rates. Studies show that 20-30% of people who suffer a hip fracture die within a year, often due to complications such as infections, deep vein thrombosis, or pulmonary embolism.

Post-Fracture Complications: Osteoporotic fractures can lead to complications such as pneumonia, pressure ulcers, and infections, particularly in elderly patients. These complications can be life-threatening, especially in those with other underlying health conditions.

Decreased Life Expectancy: The general decline in health following a major fracture, combined with the increased risk of subsequent fractures, contributes to a decrease in life expectancy among osteoporosis patients.

Impact on Quality of Life

Quality of Life: The combination of pain, disability, and loss of independence can severely impact the quality of life for people with osteoporosis, leading to depression and a reduced ability to engage in social and physical activities.

Economic and Social Burden

Economic Impact: The costs associated with treating osteoporotic fractures and the need for long-term care add to the economic burden on families and healthcare systems. The social burden includes the emotional and physical strain on caregivers.

Importance of Early Detection and Management

Early detection through screening, along with appropriate management (including medication, lifestyle changes, and fall prevention strategies), can reduce the risk of fractures and help mitigate the morbidity and mortality associated with osteoporosis.

Risk of Subsequent Fractures: An osteoporotic fracture begets another fracture. This simply means that if a patient has a fracture, the risk of getting a second osteoporotic fracture is more than double the general population in the following year. Hence, appropriate assessment and treatment after the first osteoporotic fracture is vital to prevent the second and subsequent fractures.

Access to an Orthopaedic Surgeon: In Malaysia, access to an orthopaedic surgeon in the public setting (Government Hospital) is usually through a referral from a general practitioner or other specialists. Access to an orthopaedic surgeon in the private setting is available on a walk-in (by appointment) basis without the need for a referral.

First Encounter: Most of the time, however, the patient encounters the orthopaedic surgeon for the first time only after a low-trauma fracture has already happened, i.e., hip fracture, wrist fracture, spine fracture.

Orthopaedic Surgical Management for Osteoporotic Fractures

The orthopaedic surgeon assesses the patient’s injury through physical examination and imaging studies (X-rays, CT scans, MRIs) to determine the type and extent of the fracture.

Fracture Fixation

Surgical Fixation: For fractures caused by osteoporosis, the orthopaedic surgeon may perform surgical fixation using plates, screws, rods, or nails to stabilise the bone and promote healing.

Hip Fractures

Surgical Intervention: Hip fractures, which are common in osteoporosis, often require surgical intervention. This may involve internal fixation (using screws or a rod), hemiarthroplasty (partial hip replacement), or total hip replacement.

Wrist Fractures

Surgical Fixation: These may require surgical fixation using pins, plates, or external fixation devices, especially if the fracture is displaced.

Spine Fractures

Vertebroplasty or Kyphoplasty: Vertebral compression fractures may be treated with procedures such as vertebroplasty or kyphoplasty, where bone cement is injected into the fractured vertebra to stabilise it and relieve pain.

Non-Surgical Orthopaedic Treatment for Osteoporotic Fractures

Casting or Bracing

Immobilisation: In some cases, especially with less severe fractures or fractures in patients who are not surgical candidates, the orthopaedic surgeon may opt for immobilisation using casts or braces.

Collaboration with Other Healthcare Providers

Comprehensive Management: The orthopaedic surgeon may collaborate with the patient’s primary care physician or endocrinologist to ensure appropriate management of osteoporosis. This could include medications such as bisphosphonates, calcium, and vitamin D supplements to strengthen bones.

Fall Prevention: For fall prevention, the surgeon may recommend fall prevention strategies, including home safety assessments, balance training, and assistive devices like walkers or canes.

Patient Education: Educating patients about maintaining bone health through diet, exercise, and lifestyle changes is also a key aspect of the orthopaedic surgeon’s role.

Who Should Get Osteoporosis Treatment in Malaysia?

In Malaysia, postmenopausal women should be considered for treatment if they fulfil any of the following, after exclusion of secondary causes of osteoporosis:

Presence of Low Trauma Fracture

Criteria: Postmenopausal women with low trauma hip, spine, wrist, or any other major fragility fracture (clinical or asymptomatic) should be considered for treatment.

T-Score of -2.5 or Lower

BMD Scan: Women with a T-score of -2.5 at the femoral neck, total hip, or lumbar spine on a BMD scan should be considered for osteoporosis treatment.

Osteopenia with High Fracture Risk

FRAX® Tool: Patients with osteopenia (T-score between -1.0 and -2.5) and a Fracture Risk Assessment Tool (FRAX®) calculated 10-year fracture probability of more than 3% for hip fractures and more than 20% for major osteoporotic fractures should receive treatment.

In Malaysia, osteoporosis treatment typically includes a range of medications that help to strengthen bones and reduce the risk of fractures. The choice of medication depends on the patient’s specific needs, medical history, and risk factors. A prescription is required for these medications, and medical evaluation is needed before and during treatment.

Types of Osteoporosis Medications

Bisphosphonates

Examples: Alendronate (Fosamax), Ibandronate (Bonviva), Risedronate (Actonel), Zoledronic acid (Reclast).

Function: These medications (anti-resorptive) inhibit bone resorption by osteoclasts, helping to increase bone density and reduce fracture risk.

Administration: Oral forms (daily, weekly, or monthly) or intravenous (usually yearly).

Selective Oestrogen Receptor Modulators (SERMs)

Example: Raloxifene (Evista).

Function: Mimic oestrogen’s beneficial effects on bone density without some of the risks associated with hormone replacement therapy.

Administration: Oral, typically daily.

Hormone Replacement Therapy (HRT)

Examples: Oestrogen or combined oestrogen and progesterone (Tibolone).

Function: HRT can help maintain bone density in postmenopausal women but is generally used for short term (3 – 5 years) with interval assessments to determine whether to continue, taper, or switch to other osteoporosis treatments. HRT is ideally initiated within two years of menopause.

Administration: Oral, transdermal patches, or topical forms.

RANK Ligand Inhibitor

Example: Denosumab (Prolia).

Function: This is a monoclonal antibody that inhibits the RANKL protein, reducing bone resorption (anti-resorptive) and increasing bone density.

Administration: Subcutaneous injection every six months.

Parathyroid Hormone Analog

Example: Teriparatide (Forteo).

Function: This is a recombinant form of parathyroid hormone that stimulates bone formation. It is typically used in cases where other treatments have failed or in high-risk individuals.

Administration: Daily subcutaneous injection (for 12 – 24 months).

Calcium and Vitamin D Supplements

Function: Essential for bone health and often used in conjunction with other osteoporosis treatments to ensure adequate calcium and vitamin D levels.

Administration: Oral supplements.

Vitamin D and Calcium: Vitamin D supplementation (at least 800 IU/day) in combination with calcium (1200 mg/day elemental calcium) is recommended for fracture and fall prevention in people above 50 years of age who are at risk of fractures, particularly when initiating active osteoporosis therapies.

Types of Vitamin D Supplements: Vitamin D supplements are available as either ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3). Vitamin D2 is derived from plant sources and vitamin D3 from animal sources or exposure to sunlight.

Blood Levels of Vitamin D: Blood levels of 25-hydroxy vitamin D (25(OH) D) provide the best index of vitamin D stores. Different threshold levels have been put forth as optimal for skeletal health. The Malaysian Clinical Practice Guidelines recommend a 25(OH)D level above 30 ng/ml (75 nmol/L). This level could reduce falls among older people, which could indirectly reduce the risk of fractures.

Both calcium and vitamin D are prescribed alongside pharmacological treatments of osteoporosis.

Access and Availability of Osteoporosis Medication

In Malaysia, these medications are available through hospitals, clinics, and pharmacies. Healthcare providers will assess the best treatment options based on individual patient profiles. It is important for individuals to consult with their healthcare providers to determine the most appropriate medication and dosage for their specific condition and needs. A prescription is required for these osteoporosis medications, and medical evaluation is required before treatment.

Conclusion on Osteoporosis in Malaysia

The role of the orthopaedic surgeon in osteoporosis-related fractures is multifaceted, involving the acute management of fractures, postoperative care, prevention of future fractures, and coordination of care. Through surgical expertise and a holistic approach to patient management, orthopaedic surgeons play a pivotal role in improving outcomes and quality of life for patients with osteoporosis.

Orthopaedic surgeons play a crucial role in raising awareness about osteoporosis and the importance of early detection and treatment. By providing information and support, they empower patients to take an active role in managing their bone health and preventing future fractures.

For more information or to schedule an appointment with Dr. Maria Wong, please visit drmariawong.com and take the first step towards improving your musculoskeletal health.