Contributing factors may alter management of osteoporosis

An 85-year-old man slipped on the ice and fractured his right wrist and was also found to have a non-displaced pubic ramus fracture. Further evaluation revealed three old vertebral fractures. His spine BMD could not be accurately assessed because of the fractures but his femoral neck T-score was –2.2. Aside from his age, his historical risk factors for fracture were that he had a partial gastrectomy 40 years earlier with a further gastric procedure four years ago. He also took omeprazole, which was recently reported to be a risk factor for fracture.

On exam, he looked his stated age but had marked wrinkling of his face, often seen in hypogonadism. Further questioning revealed recent development of painful nipples and examination did reveal bilateral breast tissue. His testes were of normal volume, but were soft. A biochemical panel was normal, aside from an estimated glomerular filtration rate of 55, and the complete blood count was normal. Other lab studies were ordered, including mammograms and these will be discussed next week when they are available. Think about what studies you might order.

The main take-home message, at least for me, is that what appeared initially to be simple age-related osteoporosis almost certainly has other contributing factors—gastrectomy and use of proton pump inhibitors, as well as possible hypogonadism—that will substantially alter the management.