IM25.{8,12-14} | Geriatric Musculoskeletal Disorders — Summary & Reflection

KEY TAKEAWAYS

Osteoporosis: WHO definition T-score ≤−2.5 on DEXA; fragility fracture = diagnostic regardless of DEXA. Types: postmenopausal (oestrogen deficiency), senile (age-related), glucocorticoid-induced (most common secondary cause — ≥5 mg prednisolone ≥3 months). Classic fractures: vertebral (commonest), hip (most dangerous, 20–25% 1-year mortality), Colles. Treatment: calcium 1000–1200 mg/day + vitamin D 800–1000 IU/day + alendronate 70 mg/week (first-line) or zoledronic acid 5 mg IV/year; denosumab (RANKL antibody) if bisphosphonate intolerant; teriparatide (anabolic) for severe disease. Post-hip fracture: surgery within 48 hours (FIX 48); zoledronic acid IV before discharge (HORIZON trial — 35% fracture reduction).

Osteoarthritis: Whole-joint disease; most common: knee, hip, hands (Heberden's/Bouchard's nodes), spine. Key feature: morning stiffness <30 min (vs RA >60 min). X-ray LOSS: joint space Loss, Osteophytes, Subchondral Sclerosis, Subchondral cysts. Management: weight loss (most effective in obese), physiotherapy, topical NSAIDs first-line; oral NSAIDs short-term with PPI; avoid in CKD <50 mL/min; intra-articular steroids for flares; total joint replacement for severe disease.

Falls: 30% of community-dwelling elderly fall annually. Multifactorial: intrinsic (muscle weakness, balance, cognition, vision, orthostatic hypotension) + medications (benzodiazepines highest risk) + environment (rugs, lighting, grab bars). TUG >14 sec = significant risk. Prevention: multifactorial intervention (exercise/Otago programme, medication review, vision, home modification, vitamin D).

Common fractures: Hip (FIX 48 principle; zoledronate post-op), vertebral (conservative/vertebroplasty), Colles (closed reduction ± K-wire), pelvic ramus (conservative).

REFLECT

Return to Meenakshi from the hook — her hip fracture is the culmination of decades of bone loss, progressive OA, medication-related hazards (ibuprofen accelerating CKD and masking OA pain), and accumulated fall risk. Had she attended her GP annually from age 60, the DEXA scan at 65 might have identified osteopenia; bisphosphonate treatment might have maintained her bone density; physiotherapy for the knee OA might have preserved her gait; and an NSAID review might have protected her kidneys. The hip fracture was preventable. As a physician, how would you incorporate preventive geriatric assessment — screening for osteoporosis, reviewing falls risk medications, and assessing gait — into a routine consultation with a 65-year-old woman? The investment in prevention vastly exceeds the cost of treating a hip fracture and its consequences.