GC235 Osteoporotic Related Fractures
Fragility fractures occurring at sites such as the hip, vertebrae, and distal radius due to reduced bone mineral density and microarchitectural deterioration characteristic of osteoporosis.
Osteoporotic Related Fractures
This lecture (GC 235, Prof. Christian Fang) is a core orthopaedic lecture paired with the endocrine-focused GC 031 (Dr. David Lui). Together they form the complete exam-testable syllabus on osteoporosis and fragility fractures. GC 235 emphasises the surgical decision-making side: how to classify hip fractures, choose between internal fixation and arthroplasty, manage distal radius fractures and vertebral collapses, recognise atypical femoral fractures, and understand the key anatomy (blood supply to the femoral head, trabecular patterns). GC 031 emphasises the medical side: diagnosis via DEXA, risk factors, pharmacotherapy, and fracture risk stratification. Both are high-yield for Fourth Summative SAQ, MCQ, and minicases.
Learning Objectives (from the slides) [1]:
- Osteoporotic hip fractures – diagnosis, treatment, pathological considerations
- Osteoporosis – definition, diagnosis, treatment
- Other fragility fractures – distal radius, vertebral collapse
- Atypical femoral fractures (bisphosphonate-related)
1. Osteoporosis – Definition, Pathophysiology & Diagnosis
"Systemic skeletal disorder characterised by low bone mass, micro-architectural deterioration of bone tissue, leading to bone fragility and consequent increase in fracture risk." [1]
Why this matters from first principles: Bone is not static. It constantly remodels – osteoclasts resorb old bone, osteoblasts lay down new bone. When resorption exceeds formation (↑ osteoclast activity or ↓ osteoblast activity), net bone mass falls. The trabeculae thin and disconnect, cortices thin, and the bone loses its structural scaffold, making it fracture with forces that would never break healthy bone.
Key Distinction: Osteoporosis vs Osteomalacia
Osteoporosis: ↓ total bone mass, but the mineral-to-osteoid ratio is normal. The bone that exists is properly mineralised – there's just not enough of it.
Osteomalacia: ↓ mineralisation of osteoid. There is osteoid present but it fails to calcify properly (e.g. vitamin D deficiency in adults, rickets in children). The mineral-to-osteoid ratio is reduced.
Most common metabolic bone disease. 1 in 3 postmenopausal women, 1 in 5 men ≥50 years will sustain an osteoporotic fracture in their lifetime. 1 osteoporotic fracture occurs every 3 seconds worldwide. [2]
- Hip and vertebral fractures are the hallmark complications [2].
- > 50% of hip fracture survivors cannot return to their premorbid state; 10% need extra help in daily care [1].
- 1-year mortality after hip fracture in the elderly is approximately 20–30% (mostly from medical complications: PE, pneumonia, MI).
| Category | T-Score | Meaning |
|---|---|---|
| Normal | ≥ −1.0 | BMD within 1 SD of young adult mean |
| Osteopenia | −1.0 to −2.5 | Low bone mass, increased fracture risk |
| Osteoporosis | ≤ −2.5 | Significantly reduced BMD |
| Severe osteoporosis | ≤ −2.5 + fragility fracture | Established disease with clinical consequence |
- T-score: number of standard deviations below the peak bone mass of a 30-year-old of same sex and ethnicity. Used in postmenopausal women and men ≥50.
- Z-score: compared to age-matched controls. Used in premenopausal women and men < 50. If Z ≤ −2.0 → suspect secondary cause [3].
- FRAX score: 10-year probability of major osteoporotic fracture (MOF) or hip fracture. Useful for treatment decisions in osteopenia [3].
Osteoporosis diagnosis is shown on the lecture slide with the DEXA thresholds [1].
The lecture categorises risk factors into two groups [1]:
A. Increased risk of FALLS:
| Factor | Why it matters |
|---|---|
| Concurrent medical illness | General debility → impaired balance |
| Drugs – tranquillisers, alcohol | CNS depression → impaired coordination |
| Dementia / Sarcopenia / Visual impairment | Cannot perceive hazards, cannot react |
| Reduction in protective responses | Cannot break fall effectively |
| Loss of local shock absorbers | ↓ subcutaneous fat over greater trochanter |
B. Loss of bone strength:
| Factor | Why it matters |
|---|---|
| Drugs – corticosteroids, anticonvulsants, thyroxine, alcohol | Corticosteroids ↑ osteoclast activity and ↓ osteoblast activity; AEDs induce hepatic CYP450 → ↑ vitamin D catabolism |
| Smoking | Direct toxic effect on osteoblasts; ↓ oestrogen levels |
| Vitamin D deficiency | ↓ intestinal calcium absorption → secondary hyperparathyroidism → ↑ bone resorption |
| Calcium deficiency | Insufficient substrate for bone mineralisation |
| Physical inactivity | Wolff's law – bone responds to mechanical loading; no load → bone loss |
Secondary causes worth screening for: Cushing's/exogenous steroids, hyperthyroidism, hyperparathyroidism, hypogonadism, myeloma, CKD (renal osteodystrophy), IBD, RA, drugs (PPI, cyclosporine) [3][4].
2. Osteoporotic Hip Fractures – The Core of the Lecture
82-year-old woman, walks with stick, IHD on aspirin, slip and fall on level ground, left hip pain, unable to walk. [1]
Physical exam findings:
- Left hip painful to any movement
- Lower limb shortened
- Externally rotated [1]
Why shortened and externally rotated? The hip flexors (iliopsoas) and external rotators pull the distal fragment upward and outward once the femoral neck fractures. The leg cannot resist gravity and muscle pull, so it shortens and rotates externally. This is the classic posture of a displaced neck of femur fracture.
Shenton's line is an imaginary curved line drawn along the inferior border of the superior pubic ramus and the medial border of the femoral neck. If this line is disrupted (broken), a femoral neck fracture is present [1].
This is a simple, high-yield radiological sign on AP pelvis X-ray.
The blood supply to the femoral head is retrograde – retinacular arteries from the medial and lateral circumflex femoral arteries run along the neck beneath the capsule to reach the head. The ligamentum teres artery is NOT effective in adults. The epiphyseal blood supply is dominant. [1]
Why this is critical: An intracapsular fracture can tear these retinacular vessels. Because the blood supply runs retrogradely (from distal to proximal along the neck), any displacement of an intracapsular fracture risks devascularising the femoral head → avascular necrosis (AVN). This is the entire rationale for the surgical decision tree.
| Feature | Intracapsular (Neck of Femur) | Extracapsular (Trochanteric) |
|---|---|---|
| Location | Within the hip joint capsule | Outside the capsule |
| Blood supply risk | HIGH – retinacular vessels disrupted | LOW – good blood supply in trochanteric region |
| AVN risk | High (especially if displaced) | Negligible |
| Non-union risk | High | Low (cancellous bone heals well) |
| Key concern | Save vs replace the femoral head | Restore neck-shaft angle, choose correct implant |
Intracapsular fracture – worry of AVN, non-union. Extracapsular fracture – worry of fixation stability and mechanical alignment. [1]
Garden classification is the standard classification for femoral neck fractures [1]:
| Garden Grade | Description | Displacement | Trabecular Pattern |
|---|---|---|---|
| I | Incomplete / valgus impacted | Undisplaced | Trabeculae angulated into valgus |
| II | Complete but undisplaced | Undisplaced | Trabeculae aligned normally |
| III | Complete, partially displaced | Displaced | Trabeculae disrupted, femoral head rotated |
| IV | Complete, fully displaced | Displaced | No trabecular continuity, head free-floating |
Simplified for clinical practice: Garden I & II = undisplaced; Garden III & IV = displaced [1].
AVN risk [1]:
- Minimally displaced fracture → < 10% AVN risk
- Displaced fracture → ~50% AVN risk
Trabecular pattern: compressive (medial calcar) and tensile (lateral) trabeculae are shown on the slide. The alignment of these trabeculae on X-ray helps determine the Garden grade [1].
Considerations: AGE, Displacement, Save the femoral head in young age / undisplaced [1].
Other factors [1]:
- Time of presentation → AVN risk increases after 6 hours
- Patient's general health
- Risk factors for internal fixation failure: osteoporosis, too comminuted, sepsis
Factors with increased risk for fixation failure: Old age, Osteoporosis, Vertical fracture pattern, Delayed presentation [1]
| Scenario | Treatment | Rationale |
|---|---|---|
| Undisplaced (Garden I/II) | Internal fixation (cannulated screws) | Prevent displacement; preserve native hip; AVN risk low (< 10%) |
| Displaced (Garden III/IV) – Young patient | Reduction + Internal fixation | Salvage the joint – young patients tolerate reoperation if needed; native hip is worth saving |
| Displaced (Garden III/IV) – Old patient | Hemiarthroplasty | Prevent reoperation and control pain; AVN rate ~50% makes fixation unreliable |
Garden I (valgus impacted fracture) → internal fixation to prevent displacement [1]
High Yield – Garden I Trap
A valgus impacted (Garden I) fracture may look nearly normal on X-ray. The trabeculae appear angulated into valgus. If missed and untreated, it can displace → converting a simple fixation case into a hemiarthroplasty case. Always look for disruption of Shenton's line and abnormal trabecular angulation.
41/F, Garden IV fracture → Reduction and Internal Fixation (not hemiarthroplasty) because she is young [1]. At 6 months: union achieved, no collapse/shortening, returned to recreational walking status.
Hemiarthroplasty types [1]:
| Type | Description | Features |
|---|---|---|
| Monoblock (Austin Moore – AMA) | One-piece, uncemented | Cheap, simple; can be press-fit; risk of loosening |
| Modular Cemented Unipolar | Separate head and stem, cemented | More secure fixation; one articulation point |
| Modular Cemented Bipolar | Two articulating surfaces (inner + outer bearing) | Theoretically reduces acetabular wear; more expensive |
- Cemented vs uncemented: Cemented prostheses (e.g. Thompson) provide immediate stability and allow immediate weight-bearing; uncemented (Austin Moore) rely on bone in-growth.
- Mono-bloc vs Modular: Modular allows intra-operative adjustment of head size.
Post-operative precautions (to prevent dislocation) [5]:
- Do not squat or cross legs
- Do not flex hip > 90°
- Use abduction pillow
- Use high-low chair
3. Extracapsular (Trochanteric) Fractures
85-year-old woman, fall on level ground, right hip pain → X-ray shows extracapsular fracture [1].
Aim: Return to pre-injury status [1]
Restoration of neck-shaft angle. Avoid varus alignment of proximal fragment. Stabilize fracture to facilitate early mobilization. [1]
Why avoid varus? The normal neck-shaft angle is ~130°. If the proximal fragment tilts into varus (angle decreases), the abductor mechanism moment arm shortens → Trendelenburg gait and increased stress on the implant → fixation failure.
Two types of pertrochanteric fractures [1]:
| Feature | Stable | Unstable |
|---|---|---|
| Fracture pattern | Oblique pattern | Reverse obliquity |
| Comminution | Minimal | Significant |
| Extension | None | Subtrochanteric extension |
| Implant | Sliding hip screw (DHS) | Cephalomedullary nail |
Recognize the unstable patterns and choose an intramedullary device to reduce risk of fixation failure [1]
| Feature | DHS (Sliding Hip Screw) | Cephalomedullary Nail |
|---|---|---|
| Cost | ~$1000 (cheap) | ~$7000 (expensive) |
| Technical difficulty | Easier | More difficult |
| Iatrogenic fracture risk | Less | Higher (nail insertion can split femur) |
| Fracture pattern required | Simple, stable | Unstable, reverse oblique, subtrochanteric |
| Biomechanics | Extramedullary; allows controlled collapse | Intramedullary – mechanically stronger, shorter lever arm |
| Collapse | May allow excessive collapse in unstable patterns | Less chance of excessive collapse |
DHS length: 2 holes as good as 4 holes (Bolhofner JOT 1999, McLoughin JOT 2000) [1]
Why does the DHS allow "sliding"? The lag screw passes through a barrel on the side plate. As the fracture settles (bone resorbs at the fracture site), the screw slides within the barrel, allowing controlled impaction. This converts shear forces to compressive forces at the fracture site → promotes healing. However, in unstable patterns, excessive sliding leads to varus collapse.
Why is intramedullary fixation biomechanically stronger? The nail sits inside the medullary canal, closer to the mechanical axis. The bending moment (distance from load to implant) is much smaller than with an extramedullary plate, so less stress on the implant.
The lecture shows the AO classification [1] – used to categorise fracture complexity and guide implant choice. The key clinical takeaway is the stable vs unstable distinction described above.
4. Distal Radius Fractures
A: Extra-articular (within width of joint) – Colles or Smith fracture [1] B: Partial articular – Barton fracture [1] C: Complete articular [1]
| Fracture | Mechanism | Displacement | Key Feature |
|---|---|---|---|
| Colles' | FOOSH (fall on outstretched hand), dorsiflexion | Dorsal displacement, dorsal angulation | "Dinner fork" deformity |
| Smith's | Fall on flexed wrist (or direct blow to dorsum) | Volar displacement | Reverse Colles' |
| Barton's | Axial load + shear | Partial articular fracture-dislocation | Unstable – often needs surgery |
"Reduction if necessary, Stabilization if necessary, Rehabilitation ALWAYS" [1]
Steps for closed management:
- Hematoma block – inject local anaesthetic into the fracture haematoma [1]
- Closed reduction – longitudinal traction → disimpact fragment [1]
- Casting – 3-point fixation [1]
BEWARE: Bad cast (too tight or too loose) → loss of reduction [1]
Evaluate patient's functional demand, do a neurological exam (median nerve), fluoroscopy, CT assessment [1]
Most do NOT need an operation: non-displaced fractures, well reduced stable fractures, very low demand patients, geriatric [1]
Absolute indications for surgery: [1]
- High-grade open fracture
- Acute (progressing) median nerve palsy
- Associated carpal dislocation
High Yield – Median Nerve in Distal Radius Fracture
Always examine the median nerve (sensation over thenar eminence and palmar aspect of radial 3.5 fingers; motor – thumb opposition/abduction). The median nerve runs through the carpal tunnel just volar to the distal radius. A displaced fragment or haematoma can compress it acutely. Progressive median nerve palsy = urgent surgical indication.
Operative treatment: Open Reduction Internal Fixation (ORIF) with locking plate – used for displaced intra-articular fractures [1].
| Cast immobilization | Surgical repair | |
|---|---|---|
| Bone healing | After 4 weeks | Immediate stability |
| Mobilization | After cast removal | Early mobilization |
| Rehab | PT/OT – ROM exercises + strengthening | Strengthening after 4-6 weeks |
5. Vertebral Compression Fractures
F70, fall injury and back pain [1] – typical presentation of an osteoporotic vertebral compression fracture.
Clinical features:
- Acute mechanical back pain after minimal trauma (or spontaneous)
- Height loss, progressive kyphosis ("dowager's hump")
- Pain worse with sitting/standing, better lying down
- Tenderness on percussion over affected spinous process
Principle: Reduction if necessary, Stabilization if necessary, Rehabilitation ALWAYS [1]
From GC 031 [2]:
- Conservative: Symptoms usually improve in 6-8 weeks. Analgesia, bracing, physiotherapy.
- Vertebral body augmentation: Kyphoplasty / Vertebroplasty – inject cement into collapsed vertebral body.
- Open surgical intervention – indications [2]:
- Significant neurological deficits
- Progressive and severe kyphotic deformity
- Intractable pain
6. Atypical Femoral Fractures (Bisphosphonate-Related)
This is a distinct entity from typical osteoporotic fractures [1].
Reduced bone turnover → microfractures accumulation → stress fracture → eventual displacement with minimal trauma [1]
Bisphosphonates inhibit osteoclasts so effectively that bone remodelling virtually stops. While this prevents bone resorption, it also prevents the normal repair of micro-damage. Over years, these micro-cracks accumulate → eventually a stress fracture develops → completes with trivial force.
"Beak" sign on X-ray and "dreaded black line" [1]
The beak sign is a cortical thickening ("bumpy") on the lateral cortex of the femoral shaft with a small transverse lucent line – the stress fracture. The dreaded black line is a wider transverse radiolucent line indicating incomplete fracture propagation.
- Both-sided open reduction if bilateral involvement [1]
- Stop bisphosphonate, consider switching to teriparatide (anabolic agent) to promote bone formation and healing.
Benefit of bisphosphonates still outweighs risks [1] – atypical fractures are rare (3.2-50 per 100,000 person-years) compared to the huge number of fragility fractures prevented.
Vertebral collapse, Proximal humerus, Olecranon, Distal femur, Pelvic insufficiency fracture [1]
7.1 Upper vs Lower Limb Fractures
Lower limb – for locomotion: Difficulty with pain control with weight bearing. Significant morbidity with displacement/delayed union. [1]
Upper limb – for self-care function: Better managed by immobilization. Usually recovers with time and rehabilitative training. [1]
Translation: Lower limb fractures in the elderly almost always need surgical fixation because you need the patient walking to prevent the lethal cascade of immobility (pneumonia, DVT/PE, pressure sores, deconditioning). Upper limb fractures can often be managed conservatively.
Old age patient with fall and hip pain, unable to walk, pain on weight bearing. Repeated X-rays – no abnormality. Use advanced imaging: [1]
- MRI (Most sensitive) – shows bone oedema on T2
- Bone Scan
- CT
Why does this happen? Impacted fractures (especially Garden I) may not show a clear fracture line on plain X-ray. The trabeculae are crushed together rather than separated. MRI detects the bone marrow oedema surrounding the fracture, making it the gold standard.
9. General Assessment & Management Principles
General assessment: Mode of injury, Associated injury, General state, Medical conditions, Local features [1]
Management principles: [1]
- Avoid extensive immobilization
- Pain control
- Early function
- Management of osteoporosis
- Fall prevention
Non-pharmacological: [1]
- Exercise (weight-bearing)
- Sunlight (endogenous vitamin D synthesis)
- Nutritional (Vitamin D + Calcium) – Ca 1200 mg/day, Vit D 800-1000 IU/day
- Risk factor modification (smoking cessation, alcohol reduction)
Pharmacological: [1]
| Drug | Mechanism | Key Points |
|---|---|---|
| Bisphosphonates (Alendronate) | Inhibit osteoclast-mediated bone resorption | First-line; S/E: GI upset, ONJ (jaw osteonecrosis), atypical femoral fractures (>3 yrs) |
| Teriparatide | Recombinant PTH analogue → stimulates osteoblasts | Anabolic; for very high risk; max 2 years use; S/E: dizziness, hypercalcaemia |
| Denosumab | RANKL inhibitor → ↓ osteoclast differentiation | Potent antiresorptive; S/E: rebound vertebral fractures if stopped abruptly |
| Strontium ranelate | Dual: ↑ bone formation + ↓ resorption | Rarely used now (CV risk) |
| SERMs (Raloxifene) | Selective oestrogen receptor modulator | Reduces vertebral fractures but NOT hip fractures; suitable for low-risk postmenopausal women |
| HRT | Oestrogen replacement | Effective but ↑ breast cancer, CVD, VTE risk; now rarely used for osteoporosis alone |
| Risk Level | Criteria | Recommended Treatment |
|---|---|---|
| Very high | Multiple fractures; Recent MOF within 2 yrs; T ≤ −3.0; Fracture on antiresorptive | Anabolic agents (teriparatide) |
| High | Age ≥65 + T ≤ −2.5; FRAX MOF >20% or hip >3%; Prior fracture >2 yrs ago | Potent antiresorptives (bisphosphonates / denosumab) |
| Low | Age < 65; T ≤ −2.5; No prior fractures | Raloxifene (for females) |
From the supporting material on falls management [7]:
- Screen all persons >65 annually for fall history
- Modify risk: review medications (especially tranquillisers, antihypertensives), correct vision, physiotherapy for balance, home hazard assessment
- Vitamin D 800 IU/day reduces falls in those with low baseline levels
- Hip protectors may reduce hip fractures in nursing homes but compliance is poor
Exam Intelligence
| Trap | Correct Thinking |
|---|---|
| Giving hemiarthroplasty to a young patient with displaced NOF | Wrong – young patients get reduction + internal fixation to salvage the native joint, accepting higher reoperation risk |
| Using DHS for an unstable intertrochanteric fracture | Wrong – unstable patterns (reverse oblique, subtrochanteric extension, comminution) need cephalomedullary nail |
| Missing an occult hip fracture because X-ray is normal | Always get MRI if clinical suspicion is high with normal X-ray |
| Confusing osteoporosis with osteomalacia | Osteoporosis = ↓ bone mass, normal mineralisation; Osteomalacia = ↓ mineralisation of osteoid |
| Thinking bisphosphonate-related atypical fractures mean bisphosphonates should be avoided | Benefits of bisphosphonates still outweigh risks [1] |
| Teriparatide causing atypical femoral fracture | No – atypical femoral fractures are a bisphosphonate S/E. Teriparatide S/E = dizziness, hypercalcaemia |
| Saying raloxifene prevents hip fractures | No – raloxifene reduces vertebral fractures only, not hip fractures [7] |
- Glucocorticoid-induced osteoporosis → treat with alendronate (bisphosphonate) [8]
- Iatrogenic steroid (e.g. repeated knee injections for OA) → most likely cause of osteoporosis in a middle-aged man [9]
- Teriparatide side effect = dizziness (not atypical fracture, not GI reflux, not hypocalcaemia) [10]
- Long-term PPI → bone fractures (proven association) [11]
- Post-hip fracture DVT → classic SAQ scenario (see 2024 SAQ Q8) [12]
Past Paper Questions
Stem: "Glucocorticoid-induced osteoporosis" – Select the treatment from options including Alendronate, Folic acid, Hand splint, Hydroxychloroquine, Methotrexate, NSAIDs, Physiotherapy, Prednisolone, Sulfasalazine, TNF inhibitors.
Answer: A. Alendronate. Bisphosphonates are first-line for glucocorticoid-induced osteoporosis. Glucocorticoids directly suppress osteoblasts and enhance osteoclast survival.
Stem: "A 75-year-old woman who had a history of multiple fragility fractures decided to start teriparatide for her osteoporosis. Which of the following is a known side effect of teriparatide? A. Atypical femoral fracture B. Dizziness C. Gastroesophageal reflux D. Hypocalcaemia"
Answer: B. Dizziness. Teriparatide (PTH analogue) causes orthostatic hypotension and dizziness. Atypical femoral fractures = bisphosphonate side effect (trap answer A). GI reflux = bisphosphonate side effect (trap answer C). Hypocalcaemia = denosumab side effect (trap answer D).
Stem: "A 50-year-old business man presented to AED with severe low back pain. Weight gain over past few months. X-ray showed osteopenia and wedge fracture of L3. He had been receiving frequent injections for osteoarthritis of his knee for over 1 year. Which is the MOST LIKELY cause of his osteoporosis? A. Hyperparathyroidism B. Hypogonadism C. Hypothyroidism D. Iatrogenic due to exogenous steroid"
Answer: D. Iatrogenic due to exogenous steroid. "Frequent injections for OA knee" = intra-articular corticosteroid injections. Weight gain + osteoporosis + vertebral fracture = classic exogenous Cushing's picture. Hyperparathyroidism (A) would show hypercalcaemia. Hypothyroidism (C) does not typically cause osteoporosis (hyperthyroidism does).
Stem: "A 62-year-old lady had a fall and fractured her left neck of femur. She received orthopaedic surgical fixation with a dynamic hip screw. Three days post-op she complained of left calf pain and swelling. Left calf swollen up to knee and warm. Peripheral pulses palpable. (a) Most likely diagnosis? (b) Investigation of choice? (c) Three abnormalities in that investigation? (d) Blood test? (e) Initial management? (f) Long-term complication?"
Answer: (a) Deep vein thrombosis (DVT). (b) Duplex ultrasound of lower limb veins (compression ultrasonography). (c) Non-compressible vein, intraluminal thrombus, absent/reduced flow. (d) D-dimer (though already high post-operatively, useful if pre-test probability is intermediate). (e) Anticoagulation: LMWH → transition to DOAC/warfarin; leg elevation; compression stockings. (f) Post-thrombotic syndrome (chronic venous insufficiency).
Stem: "A 10-month-old baby admitted for right femoral shaft oblique fracture and right distal radius metaphyseal fracture. Mother reported accidental household fall 2 days ago. Both closed fractures. Active movement in all fingers and toes. Which is the MOST APPROPRIATE management?"
Answer: B. Multi-disciplinary meeting with paediatricians and medical social workers. In a 10-month-old (non-ambulatory child), a femoral shaft fracture + distal radius metaphyseal fracture is highly suspicious for non-accidental injury (NAI). Corner/metaphyseal fractures are classic for NAI. The priority is child protection, not just fracture treatment.
Stem: "A 40-year-old man complains of heartburn. Diagnosed with GORD, plan to start PPI. Concerned about side effects. Which complication has been shown to be caused by long-term PPI therapy? A. Bone fractures B. Dementia C. Enteric infections D. Pneumonia"
Answer: A. Bone fractures. Long-term PPI use is associated with increased risk of osteoporotic fractures (hip, spine, wrist). The mechanism may involve reduced calcium absorption due to reduced gastric acid. Dementia, enteric infections, and pneumonia are proposed associations but with weaker evidence.
High Yield Summary
-
Intracapsular NOF fracture: Displaced + old → hemiarthroplasty. Displaced + young → reduction + internal fixation. Undisplaced → internal fixation.
-
Extracapsular fracture: Stable → DHS. Unstable → cephalomedullary nail. Always restore neck-shaft angle.
-
Blood supply: Retrograde via retinacular arteries – disrupted by intracapsular displacement → AVN.
-
Garden classification: I/II = undisplaced. III/IV = displaced. AVN: undisplaced ~10%, displaced ~50%.
-
Distal radius: Most don't need surgery. Absolute surgical indications: high-grade open fracture, progressive median nerve palsy, carpal dislocation.
-
Vertebral compression fracture: Conservative → improves in 6-8 weeks. Surgery only for neuro deficit, severe kyphosis, intractable pain.
-
Atypical femoral fractures: Bisphosphonate >3 years. Prodromal bilateral thigh pain. Beak sign / dreaded black line. Benefits of bisphosphonates still > risks.
-
Osteoporosis: T ≤ −2.5. Treat: lifestyle + pharmacotherapy (bisphosphonates first-line; teriparatide for very high risk).
-
Occult hip fracture: Normal X-ray + clinical suspicion → MRI (most sensitive).
-
Management principles: Avoid immobilization, pain control, early function, treat osteoporosis, prevent falls.
Active Recall - Lecture Notes
[1] Lecture slides: GC 235. Osteoporotic Related Fractures.pdf [2] Lecture slides: GC 031. Back pain in an elderly woman_osteoporosis and related fractures.pdf [3] Senior notes: Maksim Medicine Notes.pdf (Endocrinology – Metabolic bone disease) [4] Senior notes: Ryan Ho Endocrine.pdf (Section 2.4 – Osteoporosis) [5] Senior notes: Maksim Surgery Notes.pdf (Hip fracture management) [6] Senior notes: Block A - Back pain in an elderly woman_ osteoporosis and related fractures.pdf [7] Medicine lecture slides: Management of Falls in Older Persons - Moncada LV 2011 (AAFP).pdf [8] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (Section B, Q4) [9] Past papers: 2024 Fourth Summative MCQ.pdf (Q31) [10] Past papers: 2023 Fourth Summative MCQ.pdf (Q29) [11] Past papers: 2022 Fourth Summative MCQ.pdf (Q40) [12] Past papers: 2024 Fourth Summative SAQ.pdf (Q8) [13] Past papers: 2025 Fourth Summative MCQ.pdf (Q47)
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