<prompt> A 75 year old female fall in the bathroom. On examination, She has fracture shaft of femur, this occurs due to:OsteoporosisOsteopetrosisPagets diseaseMetastasis  <response>: Ans. a OsteoporosisRef: Textbook of Orthopedics 4th Ed by John Ebnezar; Page No- 671 Most commonly fracture occurs in postmenopausal women due to osteoporosis.Diagnostic TestingDual-Energy X-ray Absorptiometry DEXA This scan is the gold standard test for osteoporosis. It is very precise for measuring bone density. Most common site for measuring bone density: Femoral neck and lumbar spine Indications for bone mineral density measurement: All women 65 and older. Postmenopausal women 65 with one or more risk factors for fracture. Men with risk factors for fracture. The results are reported as a T-score according to WHOs classification. The T-score is the bone density compared with what is normally expected in a healthy young adult of the same sex. The T-score is the number of units--standard deviations-- that bone density is above or below the average.Bone Mineral Density T-scoreDiagnosisT-scoreNormalGreater than or equal to 1.0OsteopeniaBetween -1.5 to -2.5Osteoporosis-2.5Severe osteoporosis-2.5 and fragility fracture T-scores are used in all postmenopausal and perimenopausal women, and in men over age 50. In all other patients including premenopausal women, z-scores are used. The Z-score is the number of standard deviations above or below what is normally expected for someone of the same age, sex, weight, and ethnic or racial origin. Z-score -2 may suggest that something other than aging is causing abnormal bone loss consider drugs causing osteoporosis such as corticosteroids.24-hour Urine Hydroxyproline Calcium loss is assessed with a 24-hour urine hydroxyproline or NTX N-telopeptide, a bone breakdown product.Rule out secondary causes Check phosphorus, alkaline phosphatase, TSH, vitamin D, free PTH, creatinine, CBC.Treatment First-line therapy is bisphosphonates or denosumab. Bisphosphonates e.g., alendronate, risedronate, ibandronate, zoledronate acts by inhibiting osteoclast mediated bone resorption by mediating osteoclast apoptosis. Zoledronate is the most potent bisphosphonate and it is the drug of choice for treatment and prophylaxis of osteoporosis. The dose 2-5mg Year. Alendronate is the drug of choice for treatment of osteoporosis caused by long term glucocorticoid therapy. Denosumab is an anti-RANK ligand antibody that acts by inhibiting stimulation of osteoclasts to form ruffled border osteoclast. It is given by subcutaneous route of dose of 60mg every six months for 3-5 years for treatment and prophylaxis of osteoporosis. And its efficacy is comparable to bisphosphonates. Repeat the bone densitometry at 2 years. If there is continued bone loss, move to these: Selective estrogen receptor modulators SERMs are second-line agents that increase bone density. Raloxifene and bazedoxifene inhibits bone reabsorption and are treatment and prophylaxis of postmenopausal osteoporosis. Raloxifene is only effective in case of vertebral fractures. Raloxifene also decrease the incidence of breast cancer and MI. Teriparatide and abaloparatide are PTH analogs that activate osteoblasts for bone matrix synthesis that augments bone formation. It is used when bisphosphonates fail. Calcitonin is a third-line therapy. 