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Q5: What are the principles of long-term management? A5 The fracture, although painful, rarely produces neurological deficit. The principal risk is that having one osteoporotic fracture is a strong risk fracture for future fractures. Further vertebral fracture can produce a fixed kyphosis. Fracture of the hip is the most serious of the osteoporosis-associated fractures; up to one-third may die and only one-third will return to an independent existence after the fracture. Treatment involves bisphosphonates and usually calcium and vitamin D3. Further fractures despite appropriate treatment with bisphosphonates may require treatment with teriparatide, a parathyroid hormone (PTH) analogue.
Q6: What is the prognosis? A6 Treatment of osteoporosis needs to be linked to a falls prevention strategy to maximize the longer-term outlook.
CASE 3.11 – A stiff painful back and a red eye. Q1: What is the likely differential diagnosis? A1 The connection to make is iritis and ankylosing spondylitis. It is possible that no connection exists, in which case in a young person the cause of the back pain could be mechanical, post-traumatic, associated with disc disease or developmental.
Q2: How would you investigate this case? A2 A blood screen may demonstrate raised inflammatory markers. A radiograph may demonstrate sclerosis and erosion of the sacro-iliac joint and squaring of the vertebrae with calcification of the intervertebral ligaments. Magnetic resonance imaging (MRI) can demonstrate changes not visible on a radiograph. An isotope bone scan can detect inflammation in the sacroiliac joint or lower back.
Q3: How would you confirm the likely diagnosis? A3 Demonstration of the typical radiological changes, although not present in every case, is diagnostic. The presence of the human leukocyte antigen HLA-B27 gene is not diagnostic because it is found in at least 7 per cent of the general population. Its absence, however, virtually rules out ankylosing spondylitis.