A 45-year-old man comes to the emergency department due to left wrist pain after a fall. The patient was walking in his house when he tripped over a rug and landed on his outstretched hand. His wrist swelled and he applied ice, which did not improve the swelling or pain. Medical history is notable for celiac disease, hypertension, and hypothyroidism for which he is on thyroid hormone supplementation. The patient does not use tobacco, alcohol, or illicit drugs. He has no known medication allergies. BMI is 20 kg/m². Examination shows a "dinner-fork" deformity at the left wrist. The wrist is swollen and tender to palpation. Sensation over the left hand is intact, and the patient is able to move all his fingers. X-ray of the left wrist is shown below. Which of the following is the most significant risk factor for bone fracture in this patient?

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11ec25c8_d971_4a7d_bc81_d753a868fa07_MD0003_00 This patient has a distal radius (Colles) fracture after falling on his outstretched hand. Significant fracture due to a ground-level fall is uncommon and often indicates underlying bone fragility due to osteoporosis. The most common cause of osteoporosis is declining estrogen levels in women after menopause; the risk is significantly lower in men (Choice F), and osteoporosis in a young or middle-aged man suggests the presence of a secondary cause. distal radius (Colles) fracture Bone loss is very common in patients with celiac disease, largely due to malabsorption of vitamin D (impaired absorption of fat-soluble vitamins) and resultant secondary hyperparathyroidism. Bone disease may present as (otherwise) asymptomatic osteopenia/osteoporosis or as osteomalacia with bone pain, muscle weakness, and impaired ambulation. Laboratory evaluation shows low serum 25-hydroxyvitamin D and elevated parathyroid hormone levels. Alkaline phosphatase may be elevated, and hypocalcemia and hypophosphatemia may be observed in severe cases. (Choice A) The prevalence of osteoporosis increases with age, but in men it is usually seen at age >65. The risk in middle-aged men is low. (Choice B) The risk of osteoporosis is increased in patients with low body weight (BMI <18.5 kg/m²), likely due to decreased mechanical stress on the skeleton and comorbid conditions that contribute to both weight loss and osteoporosis (eg, smoking, anorexia nervosa). This patient has normal body weight. ² (Choice D) The prevalence of both hypertension and osteoporosis increases with age, and the conditions often coexist. However, hypertension does not contribute to osteoporosis, and thiazide diuretics, commonly used in hypertension, may decrease the risk by reducing renal excretion of calcium. (Choice E) Hyperthyroidism can increase the risk of osteoporosis due to accelerated bone turnover. Hypothyroidism is not a major risk factor unless thyroid hormone is chronically over-replaced. Educational objective: Osteoporosis in a young or middle-aged man suggests a secondary cause. Bone loss is common in celiac disease due to malabsorption of vitamin D. Manifestations may include asymptomatic osteopenia/osteoporosis or osteomalacia with bone pain, muscle weakness, and impaired ambulation. References: Osteoporosis in gastrointestinal diseases. (http://www.ncbi.nlm.nih.gov/pubmed/26935513)

A 45-Year-Old Man Comes to the Emergency Department Due to Left