List the major and minor risk factors that identify patients who should be assessed for osteoporosis. What examination manoeuvers increase the likelihood that a person has osteoporosis or a vertebral compression fracture?
Major Risk Factors:
- Age over 65 years
- Vertebral compression fracture
- Fragility fracture after age 40 (A fragility fracture is one that occurs with minimal trauma, such as a fall from standing height or less.)
- Family history of osteoporotic fracture
- Systemic glucocorticoid therapy for more than 3 months
- Malabsorption syndrome
- Primary hyperparathyroidism
- Propensity to fall
- Osteopenia apparent on x-ray film
- Early menopause (before age 45)
Minor Risk Factors
- Rheumatoid arthritis
- Past history of clinical hyperthyroidism
- Chronic anticonvulsant therapy
- Excessive alcohol intake
- Excessive caffeine intake
- Weight less than 57 kg
- Weight loss greater than 10% of weight at age 25
- Chronic heparin therapy
No single physical examination manoeuver is sufficient to diagnose osteoporosis or vertebral fracture without additional testing. However, the following features increase the likelihood of OP and help identify individuals who would benefit from earlier screening.
- Height loss >3cm from patient’s maximal adult height (+ LR 1.1-3.2)
- Body weight <51kg (+LR 7.3)
- Wall-to-occiput distance >0 cm (as a measure of kyphosis) (+LR 4.6)
(Distance >7cm rules in a thoracic fracture with high degree of accuracy)
- A rib-to-pelvic distance ≤2 fingerbreadths predicts occult lumbar vertebral fractures. This is measured by placing your fingers between the inferior margin of the ribs and the iliac crest at the mid-axillary line (+LR 3.8). When the rib-to-pelvic distance is 0 fingerbreadths, the +LR is 11.5.
- A tooth count of <20 teeth (+LR 3.4).
Green AD, Colón-Emeric CS, Bastian L. Does this woman have osteoporosis?. JAMA 2004 Dec. 15; 292: 2890-2900.