Table Of ContentATLAS OF
OSTEOPOROSIS
Second Edition
ATLAS OF
OSTEOPOROSIS
Second Edition
Editor
Eric S. Orwoll, MD
Professor of Medicine
Department of Endocrinology
Program Director, General Clinical Research Center
Oregon Health and Science University
Portland, Oregon
Series Editor
Stanley G. Korenman, MD
Professor of Medicine
Associate Dean
Department of Medicine
Division of Endocrinology
UCLA School of Medicine
UCLA Medical Center
Los Angeles, California
With 23 contributors
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Atlas of osteoporosis / editor, Eric Orwoll.-- 2nd ed.
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Inc1udes bibliographical references and index.
1. Osteoporosis--Atlases. I. Title: Osteoporosis. 11. Orwoll, Eric S.
[DNLM: 1. Osteoporosis--Atlases. WE 17 A8806331 2003]
RC931.073.A8562003
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O
steoporosis has long been known to be a major health care prob ed in the First Edition have been more extensively revised to reflect major
lem, in both individual and public health terms, but in the last developments. For instance, the renewed realization of the importance of
two decades tremendous increases in scientific inquiry have bone biomechanics has led to tremendous research activity in this area.
yielded a much greater understanding of the basic biology, clinical char Similarly, the idea that anabolic therapies might allow new bone to be
acter, and epidemiology of this condition. These advances have been added has been realized with the recent demonstration of the effective
translated into much more sophisticated and effective tools for clinicians ness of parathyroid hormone treatment for osteoporosis. FinaHy, several
to use in the prevention and treatment of the disease. These tools, initial chapters have been added to highlight the emergence of new fields
ly available only to specialists in endocrinology and rheumatology, are (genetics) or the expansion of others (bone densitometry and the labora
now taken advantage ofby a wide range of disciplines, and their applica tory evaluation ofbone disorders). The editor and authors endeavored in
tion is being adapted to a large variety of situations. Appropriately, the this latest edition of the Atlas to preserve the considerable strengths of the
public is also becoming more educated about these issues, and it is not First Edition and at the same time improve on it through the addition of
uncommon for clinicians to have sophisticated discussions with weH-read new information.
patients about the diagnosis, prevention, and treatment of osteoporosis. Although osteoporosis has been recognized for miHennia, the knowl
In this light, the Second Edition of the Atlas oJOsteoporosis is designed edge regarding this disorder continues to evolve. The sheer volume of
to be useful to a broad readership united in their interest in the disorder. available information, as weH as its complexity, poses considerable chal
The expert authors have encapsulated not only the weH-established basics lenges to those attempting to summarize it. To whatever extent the Atlas
of osteoporosis but also new developments in the field in a format that has succeeded in this endeavor, it is a tribute to the expert authors who
makes extensive use of graphical displays of important data. devoted time and considerable expertise to the effort. Their contributions
Issues that are weH known to be important to skeletal biology and should enable the reader to comprehend the current state of this art, and
osteoporosis (eg, nutrition, exercise, and growth) have been updated. That to benefit from it.
there is substantive new information in these areas is a testament to the
vigor ofthe field and the pace ofits advancement. Some chapters includ- Eric S. Orwoll, MD
v
LAURA K. BACHRACH, MD ROBERT F. KLEIN, MD
Professor, Department of Pediatrics Assistant Professor
Stanford University School of Medicine Department of Medicine
Stanford Medical Center Oregon Health and Science University
Stanford, California Staff Physician
Portland Veterans Administration Medical Center
PENNY R. BAINBRIDGE, BA, RGN
Portland, Oregon
Nurse Special ist
Metabolie Bone Centre PHILIPP K. LANG, MD, MBA
Northern General Hospital Associate Professor
Sheffield, United Kingdom Department of Radiology
Director
MARY L. BOUXSEIN, PHD
Division of Musculoskeletal Radiology
Assistant Professor Brigham and Women's Hospital
Department of Orthopedic Surgery Boston, Massachusetts
Harvard Medical School
Senior Research Associate ROBERT LlNDSAY, MD
Beth Israel Deaconess Medical Center Professor
Orthopedic Biomechanics Laboratory Department of Medicine
Boston, Massachusetts Columbia-Presbyterian Medical Center
New York, New York
FELICIA COSMAN, MD
Chief of Medicine
Associate Professor
Helen Hayes Hospital
Department of Medicine West Haverstraw, New York
Columbia-Presbyterian Medical Center
New York, New York ROBERT MARCUS, MD
Medical Director Professor Emeritus
Clinical Research Center Department of Medicine
Helen Hayes Hospital Stanford University School of Medicine
West Haverstraw, New York Stanford, California
Medical Advisor
RICHARD EASTELL, MD, FRCP (UK, EDINBURGH, IRELAND),
Eli Ully and Company
FRCPATH, FMEDSCI
Indianapolis, Indiana
Research Dean for the School of Medicine and Biomedical Science
Director of the Division of Clinical Sciences (North) MICHAEL R. MCCLUNG, MD
University of Sheffield Clinical Sciences Centre Assistant Professor
Northern General Hospital Medical Education
Sheffield, United Kingdom Providence Portland Medical Center
Director
LORRAINE A. FITZPATRICK, MD
Oregon Osteoporosis Center
Professor of Medicine
Portland, Oregon
Department of Internal Medicine and Endocrinology
Mayo Medical School PAUL D. MILLER, MD
Consultant Clinical Professor of Medicine
Endocrinology and Metabolism University of Colorado Medical Center
Mayo Clinic Denver, Colorado
Rochester, Minnesota Medical Director
Colorado Center for Bone Research
KARL j. jEPSEN, PHD
Lakewood, Colorado
Assistant Professor
Department of Orthopedics ERIC S. ORWOLL, MD
Mount Sinai School of Medicine Professor of Medicine
New York, New York Department of Endocrinology
Program Director, General Clinical Research Center
B. jENNY KIRATLI, PHD
Oregon Health and Science University
Research Health Scientist
Portland, Oregon
Spinal Cord Injury Center
Veterans Administration Palo Alto Health Care System
Palo Alto, California
Vtt
SUSAN M. OTT, MD ADRIAN J. SPLITTHOFF, CANDMED
Associate Professor Medizinische Fakultät der Albert-Ludwigs-Universität
Department of Medicine Freiburg im Breisgau, Germany
University ofWashington School of Medicine Research Fellow
Seattle, Washington Harvard Medical School
Department of Radiology
RICHARD l. PRINCE, MD
Brigham and Women's Hospital
Associate Professor Boston, Massachusetts
School of Medicine and Pharmacology
University ofWestern Australia JAN E. VANDEVENNE, MD
Perth, Australia Radiologist
Department of Radiology
CLiFFORD J. ROSEN, MD
University of Antwerp Medical School
Professor of Nutrition Antwerp, Belgium
University of Maine
Director NELSON B. WATTS, MD
Maine Center for Osteoporosis Research Professor
St. Joseph's Hospital Department of Medicine
Bangor, Maine University of Cincinnati College of Medicine
Director
lORAN M. SAlAMONE, PHD
University of Cincinnati Bone Health and Osteoporosis Center
Assistant Professor Cincinnati, Ohio
Department of Epidemiology
Graduate School of Public Health CARl S.WINAlSKI, MD
University of Pittsburgh Assistant Professor
Pittsburgh, Pennsylvania Department of Radiology
Director of Musculoskeletal MRI
Brigham and Women's Hospital
Boston, Massachusetts
Vttt
CHAPTER I
The Nature of Osteoporosis
Eric S. Orwoll and Robert Marcus
Osteoporotie Bone ........................................... ~ .................................... I
Bone Mass Measurement ...........................................................................3
Qualitative Abnormalities in Osteoporotie Bone ......................................................... .4
Bone Geometry ..................................................................................6
Role of Remodeling in LifelongAcquisition and Loss of Bone ................................................7
CHAPTER 2
Bone Acquisition and Peak Bone Mass
Laura K.Bachrach
Bone Mineral Acquisition .......................................................................... 12
Calcium Economies and Bone Health ................................................................. 16
Physieal Activity and Bone Mass ..................................................................... 18
Acquired Bone Fragility ............................................................................2 0
CHAPTER 3
Genetics of Osteoporosis
Robert F. Klein
Genetic Concepts ................................................................................2 8
Contribution of Genetics to Skeletal Characteristies .....................................................2 9
Methods in Genetic Investigation ....................................................................3 I
Genes and Metabolie Bone Disease ..................................................................3 5
CHAPTER 4
Factors That Influence Adult Bone Mass
Susan M. Ott
Aging and Gender ............................................................................... .42
Clinieal Factors That Affect Bone Mass ................................................................4 3
Nutritional Factors ...............................................................................4 4
Smoking,Alcohol, and Bone ........................................................................ .46
Pregnancy ..................................................................................... .4 7
CHAPTER 5
Epidemiology of Osteoporosis and Associated Fractures
Loran M. Salamone
Epidemiology of Osteoporosis ......................................................................5 2
Fracture Epidemiology ............................................................................5 6
Risk Factors for Osteoporotic Fractures ..............................................................5 9
Role of Falls ....................................................................................6 2
Impact of Osteoporotie Fractures: Mortality, Morbidity, and Cost ............................................6 3
CHAPTER 6
Radiology of Osteoporotic Fracture
Adrian J. Splitthoff,Jan E. Vandevenne, Carl S. Winalski, and Philipp K. Lang
Vertebral Compression Fractures ....................................................................6 7
Hip Fractures .................................................................................. .70
Pelvic Insufficiency Fractures ....................................................................... .72
Wrist Fractures .................................................................................7 3
Fractures of the Proximal Humerus ..................................................................7 3
Other Insufficiency Fractures ...................................................................... .74
IX
CHAPTER 7
Laboratory Assessment of Skeletal Status
Richard Eastell and Penny R. Bainbridge
Bone Turnover Markers ............................................................................7 7
Predietion of Bone Loss and Fraetures with Bone Turnover Markers ........................................ .78
Monitoring the Effeet ofTreatment on Bone Turnover Markers ............................................ .79
Bioehemieal Evaluation of Osteoporosis: Seeondary Osteoporosis ...........................................8 0
CHAPTER 8
Bone Densitometry in Osteoporosis Care
Michael R. McC/ung
Teehnology .....................................................................................8 4
Predicting Fraeture Risk ...........................................................................8 5
Diagnosing Osteoporosis ..........................................................................8 7
Monitoring Change ...............................................................................8 9
Indieations ......................................................................................9 1
Case Examples ..................................................................................9 3
CHAPTER 9
Estrogen-dependent Bone Loss and Osteoporosis
Robert Lindsay and Felicia Cosman
Biology of Estrogen Deficieney ......................................................................9 6
Effeets of Estrogen on Intermediate Markers (Bone Mass and Turnover) .......................................9 7
Effeets of Estrogen Intervention on Fraeture Oeeurrenee ..................................................9 9
Importanee of Estrogen in Men ..................................................................... 102
CHAPTER 10
Osteoporosis in Men
Eric S. Orwoll and Robert F. Klein
Incidenee and Risk .............................................................................. 10 6
Bone Mass Density and Strueture ................................................................... 109
Causes ....................................................................................... 110
Diagnosis and Evaluation .......................................................................... 1 14
Therapy ....................................................................................... I I 6
CHAPTER 11
Osteoporosis Associated with Systemic IIIness and Medications
Paul D. Miller
Osteoporosis Related to Gastrointestinal Diseases ...................................................... 120
Osteoporosis Related to Liver, Kidney, or Panereatie Diseases ............................................. 121
Osteoporosis Related to Medieation Administration ..................................................... 125
Osteoporosis Related to Bone Marrow Disorders ...................................................... 125
Osteoporosis Related to Endoerine Disorders ......................................................... 127
Osteoporosis Related to Pregnaney ................................................................. 132
Osteoporosis Related to Nutritional Deficieney ........................................................ 132
Low Bone Mass Related to Osteomalacia and Osteogenesis Imperfeeta ...................................... 132
Diseases That Might Be Deteeted in the Clinical Assessment of Patients with Metabolie Bone Disease .............. 135
x
CHAPTER 12
GI ucocortieoid-i nd uced Osteoporosis
Lorraine A. Fitzpatrick
Epidemiology and Risk Factors ..................................................................... 138
Pathophysiology ................................................................................ 139
Bone Histomorphometry ......................................................................... 139
Physieal Findings ................................................................................ 140
Radiographie Diagnosis ........................................................................... 140
Bone Scans .................................................................................... 143
CHAPTER 13
Immobilization Osteoporosis
B. Jenny Kiratli
Bone Biomechanics .............................................................................. 150
Clinical Evidence ................................................................................ 152
Long Bone Fractures After Spinal Cord Injury .......................................................... 156
Theoretieal Framework for Fracture Risk Prediction .................................................... 162
CHAPTER 14
Etiology and Biomechanies of Hip and Vertebral Fractures
Mary L Bouxsein and Karl J. Jepsen
Basie Bone Biomechanics ......................................................................... 166
Age-related Changes in Bone ...................................................................... 167
Determinants of Fracture Risk and Introduction ofthe Factor of Risk ....................................... 169
Biomechanies of Hip Fractures ..................................................................... 170
Biomechanies ofVertebral Fractures ................................................................. 171
Fracture Prevention ............................................................................. 172
CHAPTER 15
Role of Nonpharmacologie Approach to Fracture and Osteoporosis
Richard L Prince
Overview of Bone Acquisition and Maintenance ........................................................ 175
Dietary Intervention for Bone Maintenance ........................................................... 178
Role of Activity and Exercise ....................................................................... 185
CHAPTER 16
Bisphosphonate Therapy for Osteoporosis
Nelson B. Watts
CHAPTER 17
Bone Anabolie Agents
Clifford J. Rosen
Insulin-like Growth Factor ........................................................................ 196
Human Growth Hormone ........................................................................2 0 I
Parathyroid Hormone ............................................................................2 02
Sodium Fluoride ................................................................................2 04
Index ....................................................................................... .
209
Color Plates ................................................................................
217
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