The Rational Clinical Examination Section Editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and
Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor
Author Affiliations: Ambulatory Care Service
(Drs Green and Bastian) and Geriatrics Research Education and Clinical Center
(Drs Colón-Emeric and Lyles), Durham Veterans Affairs Medical Center,
and Center for the Study of Aging and Human Development (Drs Colón-Emeric,
Bastian, and Lyles) and Department of Internal Medicine (Drs Green, Colón-Emeric,
Bastian, Drake, and Lyles) Duke University Medical Center, Durham, NC.
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.
Green AD, Colón-Emeric CS, Bastian L, Drake MT, Lyles KW. Does This Woman Have Osteoporosis?. JAMA. 2004;292(23):2890-2900. doi:10.1001/jama.292.23.2890