Case History 6: Osteoporosis

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Chief Complaint: 72-year-old woman who fell on her right hip.

History: Margaret Donovan, a 72-year-old white female, was brought to the emergency room by her son-in-law after falling in her bathtub. She was previously in good health, despite leading a relatively sedentary lifestyle and having a 30-pack-year history of cigarette smoking. The only medication she currently takes is Inderal (propranolol) for mild hypertension. She fell upon entering the bathtub when her right leg slipped out from under her; she landed on her right hip. There was no trauma to her head, nor does she complain of right or left wrist pain. However, she reports severe pain in the right hip and upper thigh, and was unable to get up after her fall. An injection of oxymorphone hydrochloride (Numorphan) helped relieve her pain and she was taken to the radiology department for an X-ray of her right leg and hip.

Physical Examination: The patient was alert, oriented to time, place, and date, and was responding appropriately to questions despite being in considerable pain. There were no signs of trauma to the head, neck, torso, arms, or left leg. The right thigh and hip were extremely tender and were immobilized by a leg splint. Heart and lung sounds were normal, and abdominal sounds were reduced.

Radiology Report: The X-ray of the right hip revealed a complete, comminuted, intertrochanteric fracture of the right hip. No other fractures were noted in the right leg. There were also long-term osteoporotic changes in the femur, tibia, and fibula.

Questions:

1. What is meant by a "complete, comminuted, intertrochanteric fracture of the right hip"?

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2. Draw a picture of what you think Margaret's fracture looks like.

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3. The radiologist reported signs of osteoporosis. Describe the characteristics of an osteoporotic femur as seen on an X-ray. (How does it differ in appearance from a normal femur?)

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4. Describe the microscopic features of osseous tissue that normally help long bones withstand lateral stress without breaking.

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5. Describe the microscopic features of osseous tissue that normally help long bones withstand compressive stress without breaking.

Surgeons performed an open reduction of Margaret's fracture, immobilizing the bones with internal pins.

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6. Describe the changes that a broken bone undergoes as it is healing.

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7. During her long recovery, Margaret is advised by her physician to begin weight-bearing as soon as she can. How does weight-bearing influence the process you described in question #6? (Be specific in your answer and describe what weight-bearing does to bone at the microscopic level.)

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8. Aside from any effect on the healing process, why else might Margaret's physician want her to avoid a prolonged period of bed-ridden inactivity?

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9. What risk factors does Margaret have for osteoporosis?

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10. What parts of the skeleton (i.e. what bones) are most vulnerable to the ravages of osteoporosis?

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11. Following her recovery, Margaret was placed on three medications: (A) oral calcium supplementation,(B) oral estrogen, and (C) oral alendronate sodium (Fosamax). Specifically describe how each of these medications works to treat Margaret's condition.

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12. Other treatments for osteoporosis include (A) sodium fluoride and (B) calcitonin. Describe how each of these medications works to treat osteoporosis.

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