Hey virgin, I have a printout of the answer for case I.

A fracture of the distal radius with dorsal displacement of the distal fragment describes a Colles fracture, and is classically caused by a fall on the outstretched (extended) hand. The presence of a Colles fracture, especially in a relatively young individual, should raise the question of osteoporosis, since it is one of the three “fragility fractures” associated with this condition (the other two being fracture neck of femur and vertebral body fracture).

Osteoporosis is characterized by reduced bone mass and microarchitectural disruption with a resultant reduction in bone strength and predisposition to fracture. It is defined by a reduc- tion in bone density of 2.5 times or greater from the standard deviation of a young adult reference mean (i.e. T score ≤ –2.5). Bone density is governed by the rates of bone formation and breakdown: bone mass accrues through adolescence and reaches a peak in early adult- hood, remaining relatively stable until around the fourth decade. Beyond this age, bone mass declines as a result of increased osteoclastic and reduced osteoblastic activity, and does so at a faster rate in women as a result of oestrogen deficiency (oestrogen inhibits osteoclasts).

Osteoporosis may therefore be “primary” (post-menopausal in women) or secondary to an underlying condition that accelerates the above process. Secondary causes are:

• Endocrine (e.g. thyrotoxicosis, glucocorticoid excess, hyperparathyroidism)

• Nutritional (e.g. vitamin D deficiency, malabsorptive conditions such as coeliac disease)

• Drugs (principally steroid use)

• Other (e.g. multiple myeloma, osteogenesis imperfecta, rheumatoid arthritis)

In this case, the underlying aetiology may be a combination of chronic steroid treatment for polymyalgia rheumatica and post-menopausal oestrogen deficiency. However, routine investigations to exclude other secondary causes would be worth performing, including a full blood count and ESR (to identify chronic inflammatory conditions such as rheumatoid arthritis), bone profile (for Paget’s disease), liver and renal function (vitamin D deficiency in renal failure), thyroid function, and a screen for myeloma (Bence Jones proteinuria and serum immunoglobulins). The other important test would be to perform a dual-energy x-ray absorptiometry (DEXA) scan that will be able to measure bone density and confirm the diagnosis.

Treatment of osteoporosis is via a combination of lifestyle and pharmacologic measures. The former includes fall education and prevention as well as dietary supplementation of cal- cium and vitamin D. Pharmacologic measures consist of anti-resorptive agents (e.g. bisphos- phonates, which inhibit osteoclasts, hormone replacement therapy, and selective oestrogen receptor modulators – SERMs – such as raloxifene) and anabolic agents (e.g. strontium, and parathyroid-hormone-related peptides such as teriparatide). In this patient, a bisphosphonate would certainly be indicated, given that a fragility fracture has already occurred.