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.
To review the accuracy and precision of physical examination findings
for the diagnosis of osteopenia, osteoporosis, or spinal fracture.
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.
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.
Two authors independently abstracted data from the included studies.
Disagreements were resolved by discussion.
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).
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.