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The Rational Clinical Examination | Clinician's Corner

Does This Woman Have Osteoporosis?

Amanda D. Green, MD; Cathleen S. Colón-Emeric, MD, MHSc; Lori Bastian, MD, MPH; Matthew T. Drake, MD, PhD; Kenneth W. Lyles, MD
JAMA. 2004;292(23):2890-2900. doi:10.1001/jama.292.23.2890.
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Context Although recent US Preventive Services Task Force guidelines recommend bone densitometry for all women older than 65 years, identifying younger women at increased risk for osteoporosis and women with occult vertebral fractures remains a clinical challenge. We investigated whether physical signs are useful as a screening tool either for early referral to bone densitometry or for occult spinal fractures.

Objective To review the accuracy and precision of physical examination findings for the diagnosis of osteopenia, osteoporosis, or spinal fracture.

Data Sources We conducted a MEDLINE search for articles published from 1966 through August 2004, manually reviewed bibliographies, consulted 4 clinical skills textbooks, and contacted experts in the field.

Study Selection Studies were included if they contained adequate original data on the accuracy or precision of physical examination for diagnosing osteopenia, osteoporosis, or spinal fracture. Two authors screened abstracts found by the search. Fourteen of 191 full articles reviewed met inclusion criteria.

Data Extraction Two authors independently abstracted data from the included studies. Disagreements were resolved by discussion.

Data Synthesis No single maneuver is sufficient to rule in or rule out osteoporosis or spinal fracture without further testing. The following yielded the greatest positive likelihood ratios (LR+): weight less than 51 kg, LR+, 7.3 (95% confidence interval [CI], 5.0-10.8); tooth count less than 20, LR+, 3.4 (95% CI, 1.4-8.0); rib-pelvis distance less than 2 finger breadths, LR+, 3.8 (95% CI, 2.9-5.1); wall-occiput distance greater than 0 cm, LR+, 4.6 (95% CI, 2.9-7.3), and self-reported humped back, LR+, 3.0 (95% CI, 2.2-4.1).

Conclusions In patients who do not meet current bone mineral density screening recommendations, several convenient examination maneuvers, especially low weight, can significantly change the pretest probability of osteoporosis and suggest the need for earlier screening. Wall-occiput distance greater than 0 cm and rib-pelvis distance less than 2 fingerbreadths suggest the presence of occult spinal fracture.

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Figure. Physical Examination Tests for Detection of Occult Vertebral Fractures
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A, Wall-occiput test is used to detect occult thoracic vertebral fractures. A positive test result in this review is defined as being unable to touch the wall with the occiput when standing with the back and heels against the wall and the head positioned such than an imaginary line from the lateral corner of the eye to the superior junction of the auricle is parallel to the floor. B, Rib-pelvis distance test is used to detect occult lumbar vertebral fractures. A positive test is defined as a distance of less than or equal to 2 fingerbreadths between the inferior margin of the ribs and the superior surface of the pelvis in the midaxillary line.

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