Cough-Induced Rib Fractures in a Frequent Tea Drinker

Bruce M. Rothschild, MD


August 11, 2020

Osteoporosis is a disorder in which bone integrity is reduced. This is typically measured as decreased bone density, although that is only one component of bone strength. Osteoporosis is associated with microarchitecture deterioration, producing increased bone fragility and the propensity of bone to decompensate and fracture.[3,4] It is the most common metabolic disease with substantial implications.[5,6] More than 53 million Americans either have osteoporosis or are at high risk due to low bone mass.[7] Although more common among White women than in other ethnic groups, men are also affected. Osteoporosis among men is often due to alcohol use (45%-60%), glucocorticosteroid use, or hypogonadism.[8]

Many indicators allow the early recognition of osteoporosis.[9] Fractures that occur with minimal trauma or in the absence of identifying trauma, although not an early feature of osteoporosis, are often the first indication and are highly suggestive, as is decreased stature.[10] Fractures that occur with minimal trauma are a sign of skeletal fragility. Although severe coughing can result in fractures, repeated occurrence should raise suspicion of osteoporosis. Height loss is another sign that suggests osteoporotic compression fractures. However, height normally varies daily. Thus, comparing heights at the same time of day is important. Pathologic height alteration may be missed if an abnormal measurement is compared with a previous assessment performed at a different time. Upright posture-related intravertebral disk compression may reduce height by an inch.

Osteoporosis is often overlooked during routine clinical assessments. Its possibility has to be considered before it can be diagnosed. Fractures that occur with minimal trauma or even in the absence of identifying trauma are often mechanically treated, often without consideration of why they occurred. Such findings are highly suspicious for osteoporosis. Setting or casting a fracture only addresses half the problem. Careful consideration should be given in order to assess the likely presence of an osteoporotic explanation and to prevent future events.

Lateral chest x-ray images are an often overlooked, routinely available resource for recognition of osteoporosis. They often contain evidence of compression fractures. However, a radiologist's evaluation of chest radiographs may be so frequent and routine that pathologic findings in the vertebral column (also visible on a chest x-ray, especially the lateral view) is often overlooked.[11] Personal examination of the chest x-ray by the physician is important. Compression fractures are readily recognizable on a lateral chest x-ray and usually identify the presence of osteoporosis.

In terms of bone density studies, the range of normal values is predicated on intact vertebrae. Bone density in the presence of vertebral compression fractures is the composite of the original bone and added compression. Bone density measurement in the spine in patients with compression fracture should exclude the vertebrae with fractures. However, bone density of the hips can and should be performed.

Whether bone density measurement is essential after identifying osteoporosis through the presence of vertebral compression fractures can be debated. Bisphosphonates are considered the drugs of choice for initial treatment of osteoporosis.[12] When bisphosphonates are used for treatment, bone density screening for effectiveness may be been recommended. Alternatively, in patients with fractures, an anabolic agent may be considered. Bone density studies are not used to assess calcitonin efficacy because this agent improves bone strength but does not actually affect density. However, calcitonin is not widely recognized as a primary option for initial treatment.


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