KELAINAN METABOLIK DAN

ENDOKRIN PADA ORTHOPAEDI

dr. Ronald V. Munthe SpOT
Divisi Orthopaedi & Traumatologi
Bagian Bedah RS UKI
BONE COMPOSITION
Bone mineral : mainly Ca & P
Matrix : Kolagen, BMP
Bone cells : osteoblast, osteocyte, osteoclast
Bone cells
Osteoblast
Dari sel sel prekursor mesenkimal bone marrow
dan periosteum
Tertanam dalam matrix osteosit

Osteoclast
Dari sel sel Mononuclear bone resorption
AGE RELATED CHANGES IN BONE
Childhood
Gets longer & wider
Bone tissue quite light & porous
Between puberty & 30 years of age
Heavier & stronger
Bone mass increase 3%/year
Peak bone mass
> 30 years
0,5%/year (bone loss)
Menopause 10yrs
- bone loss in women 3%/yr
- bone depletion in black << white
65 75 yrs
- bone loss 0,5 %/yr
Men 15 or 20 years later than women
OSTEOPOROSIS
Systemic skeletal disease low bone mass and
microarchitectural bone fragility fracture
risk
 Bone Mass Density

WHO: utilizes Bone Mineral Density as definition (T score <-2.5);

BMD diukur dengan metode DEXA (Dual Energy X-ray
Absoptiometry)
 Some causes of osteoporosis
Nutritional Malignant disease
Scurvy Carcinomatosis
Malnutrition Multiple myeloma
Malabsorption Leukaemia

Endocrine disorders Non-malignant disease

Hyperparathyroidism Rheumatoid arthritis
Gonadal insufficiency Ankylosing spondylitis
Cushings disease Tuberculosis
Thyrotoxicosis Chronic renal disease

Drug-induced Idiopathic
Corticosteroid Juvenile osteoporosis
Alcohol Postclimacteric osteoporosis
Heparin
Faktor Risiko Osteoporosis
Tidak dapat diubah Dapat diubah

Usia lebih tua.

Perempuan Hormon sex yang rendah,
(esterogen atau
Ethnicity
testosteron).
Struktur tulang yang kecil
Malnutrisi / intake kurang
Family history
Alkoholism
Merokok
Kadar Vit D dan Kalsium
Kurang aktivitas.
Prolong Imobilization
Kurang terpapar sinar
matahari
Gambaran Klinis
Tinggi badan berkurang
Bungkuk atau bentuk tubuh berubah
Fraktur dengan energi trauma yg tdk significant
(trivial injury)
Back pain
Vertebral Fracture Cascade
The most common
breaks in weak bones
are in the wrist, spine
and hip.

13
Osteoporosis Prevention and Treatment

Hormonal Replacement
Treatment SERM
choice Bisphosphonates
Strontium
PTH

Vitamin D
Life Style

20 40 60 80 Age
 15

Medications

Bisphosphonates
(Fosamax) - Alendronate &
Alendronate with Calcium
(Boniva) - Ibandronate (Updated 2006)
(Actonel) - Risedronate & Risedronate
with Calcium
(Miacalcin) Calcitonin
Estrogen Therapy/Hormone Therapy
Parathyroid Hormone (PTH 1-34)
Selective Estrogen Receptor Modulator (SERM)
(Evista) Raloxifene
RICKETS AND OSTEOMALACIA
Gangguan mineralisasi pada tulang ok
defisiensi atau gangguan metabolisme Ca, P dan
Vit.D

In children, effect on physeal growth &

ossification deformities of the endochondral
skeleton (rickets)
In adult, Bone tissue throughout the skeleton is
incompletely calcified softened osteomalacia
Etiologi
Nutritional deficiency
Malabsorbsi saluran cerna
Renal Tubular Defect
Renal Osteodysthrophy
Fibrous dysplasia
Tipe Rickets
Nutritional rickets
mis : malnutrisi
Vitamin D-resistant rickets
mis : X-linked hypophosfatemia
Vitamin D-dependent rickets
mis : malabsorbsi pada GI
Gambaran Klinis
Anak anak.
Tetany/convulsions, failure to thrive, kelemahan
otot.
Perubahan pada tulang craniotabes, penebalan
pada daerah lutut, ankle and wrist.
Rickety rosary enlargement costochondral
junction
Harrisons sulcus lateral indentation of chest
Bila pada anak2 yang sudah berjalan genu varum
atau valgum, swollen joints & disturbed gait
Spinal curvature, long bone fracture
 Ricketsia
Defek mineralisasi pada tulang
immature karena defisiensi Vit.D,
calcium and phosphate
Lempeng physeal melebar, penipisan
korteks tulang dan bowing.
Laboratory :
low to normal serum calcium
low serum phosphate
elevated alkaline phosphatase
elevated parathyroid hormone

Cats back (thoracic

Rossary sign kyphosis)
Dewasa
Nyeri pada tulang, LBP, kelemahan otot
Vertebral collapse kyphosis
Unexplained pain in the hip stress fracture
 X-rays
Active rickets
Thickening & widening growth plate
Cupping metaphysis
Bowing diaphysis
X Ray
Osteomalacia
Looser zone (garisan transverse radioluscent pada
ramus pubis atau colum femur)
Biconcave vertebrae ( codfish)
Trefoil pelvis (champagne glass pelvis)
Osteomalacia Osteoporosis

Common in ageing women

Prone to pathological fracture
Decreased bone density

Unwell Well
Generalized chronic ache Pain only after
fracture
Muscle weak Muscles normal
Loosers zone No loosers zone
Alkaline phosphatase Normal
increased
Serum phosphorus decreased Normal
HYPERPARATHYROIDISM

Primary Adenoma/hyperplasia
Secondary Persistent hypocalcemia
Tertiary Secondary hyperplasia leads to
autonomous overactivity
 Secretion of PTH

Increase tubular Increased Increased

reabsorption of Ca 1,25-DHCC osteoclastic activity

Increased intestinal Bone resorption

absorption of Ca
Release of Ca from bone

Serum Ca rises
PRIMARY HYPERPTH
>> solitary adenoma in one of the small glands
2x>
Gambaran klinis
Hypercalcemia : anorexia, nausea, abdominal pain,
depression, fatigue & muscle weakness
Hypercalciuria : polyuria, kidney stones or
nephrocalcinosis
Chondrocalcinosis : joint symptoms
Bone disease (<10%) : general osteoporosis &
pathological fracture
 X-rays
Osteoporosis & cortical erosion
Classic subperiosteal cortical resorption of the
middle phalanx
Laboratorium
Hypercalcemia
Hypophosphatemia
Serum PTH
Alkaline phosfatase
Penatalaksanaan
Biasanya konservatif, perbaikan status hidrasi dan
Ca intake
Parathyroidectomy
marked & unremitting hypercalcemia
Recurrent renal calculi
Progressive nephro calcinosis
Severe osteoporosis
SECONDARY HYPERPARATHYROID
Response to chronic hypoCa
Penatalaksanaan langsung ditujukan pada
penyebab primernya.
RENAL OSTEODYSTROPHY
Gagal ginjal kronis GFR Hipocalcemia &
Pembentukan Vit.D HiperPTH sekunder

X-ray
Osteoporosis
widened & irregular epiphyseal plates gambaran rickets
Tx
Large dose vit D (up to 500.000 iu daily)
Epiphyseolysis internal fixation
Hemodialisis
Transplantasi ginjal
Renal Glomerular Osteodystrophy
ENDOCRINE DISORDERS
Anterior lobe of pituitary
Directly affect growth
Control activities of thyroid, gonads, adrenal cortex
Posterior lobe of pituitary
Has no influence on the musculoskeletal system

Anterior lobe
Secrete : Pituitary growth hormone
Thyrotropic gonadotropic
Adenocorticotropic
HYPOPITUITARISM
Anterior pituitary hyposecretion
Intrinsic disorders
Infarct/hemorrhage pituitary
Infection
Intra pituitary tumors
Extrinsic disorders
Craniopharyngioma
Posterior lobe dysfunc.: diabetes insipidus
HYPOPITUITARISM
Children
Lorain syndrome proportionate dwarfism
Frohlichs adiposogenital syndrom delayed
skeletal maturation
immaturity secondary sexual characteristic
epiphyseal slipped of hip/knee

Adults
Panhypopituitarism : premature osteoporosis
 Treatment
Depend on the cause
If tumor + removed or ablated
Growth hormone deff tx biosynthetic GH
(somatotropin) succesful
HYPERPITUITARISM
Oversecretion of Growth Hormone acidophil
adenoma (tumor) >>
Gigantism
Oversecretion GH pada masa anak-anak atau
remaja pertumbuhan yang dari tulang-tulang.
Mental retardation, sexual immaturity
Tx : removal of pituitary tumor
 Acromegaly
GH oversecretion pada masa dewasa
pembesaran tulang (lebih menebal) dan jaringan
lunak.
Facies acromegaly : penebalan tengkorak,
penonjolan tepi orbita, pembesaran rahang,
hidung, bibir, lidah.
Barrel shaped chest
Secondary osteoarthritis
Tx
Tumor removal.
Mild cases : give GH suppressants
( somatostatin analogue or bromocriptine, dopamin
agonist)
ADRENOCORTICAL DYSFUNCTION
Adrenal cortex secretes :
Mineralocorticoid (aldosterone)
Glucocorticoid ( cortisol) has profound effects on
bone & mineral metabolism ; supression osteoblast
activity
Ca abs
Ca excr
PTH activity
Bone resorption
Bone formation
Hypercortisonism (Cushings syndrome)
Glucocorticoid excess, caused by
Pitt secretion of ACTH
Secretion by adrenal cortex (usually due to steroid
secreting tumor)
Excessive treatment with glucocorticoid
Clinical feature ~ Cushings syndrome
Moon face
Trunk distinctly obese
Abdominal striae
X-ray : generalized osteoporosis
Penatalaksanaan
Prevention
Systemic corticosteroid only when essential & low
dose
If tx prolonged Ca supplement (>1500mg/day) +
vit D
Post menopausal & elderly men HRT
Bisphosphonates effective for bone loss & fracture
Treatment
Treat the fracture & control bone pain
If tumor + removal
THYROID DYSFUNCTION
HYPOTHYROIDISM
Congenital hypothyroidism (cretinism)
caused by
Developmental abnormalities thyroid
In endemic form in areas of iodine deffic
The child could become severely dwarfed &
mentally retarded
X-ray : irregular epiphyseal ossification
Tx : thyroid hormone is essential
 Juvenile hypothyroidism
Less severe than the congenital
Growth & sexual development retarded
X-ray : epiphyseal fragmentation appearance
Tx : thyroid hormone

Adult hypothyroidism (myxoedema)

Result from primary disorder of thyroid func &
iatrogenic suppression thyroid
Onset slow & long period of non specific symptoms
Tx : thyroxine effective & have to be continued for
life
Hyperthyroidism
Thyroxin mempercepat bone turn over resorpsi
>> formasi Osteoporosis
Fractures only in cumulative of menopause &
hyperthyroid
Tx : both osteoporosis & hyperthyroid
THANK YOU