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Fragility FractureEdit

Fragility fracture refers to a fracture that occurs from a low-energy event, such as a fall from standing height, in bones that are structurally weakened by osteoporosis or other conditions. In older adults, fragility fractures are a major cause of disability and can herald ongoing bone fragility. Common sites include the hip (proximal femur), spine (vertebral compression fractures), and wrist (distal radius). Because fragility fractures reflect underlying bone weakness, they are not only a health event but a signal that further fractures are likely if the root causes are not addressed. The burden is practical as well as medical: longer hospital stays, reduced mobility, dependence on others, and increased risk of subsequent fractures and mortality. See osteoporosis and falls for related concepts, and note that specific fracture patterns such as hip fracture and vertebral compression fracture represent the most consequential manifestations.

Epidemiology

Fragility fractures affect tens of millions of people worldwide each year, with incidence climbing sharply with age. Women are disproportionately affected, though men experience meaningful risk as well, especially in the presence of chronic diseases or long-term glucocorticoid exposure. The consequences extend beyond pain and immobility to substantial healthcare costs and strain on caregivers and health systems. In the case of hip fractures, mortality within the first year after injury often approaches or exceeds a few tens of percent in older populations, and a sizable proportion of survivors do not regain pre-injury levels of independence. See hip fracture and vertebral compression fracture for site-specific statistics and trajectories.

Pathophysiology

Fragility fractures arise when bone quantity and quality decline due to aging, hormonal changes, or disease processes. Osteoporosis is the most common underlying condition, but other factors such as sarcopenia (loss of muscle mass) and chronic illnesses can contribute to both bone weakness and a higher risk of falls. The structural integrity of bone depends on mineral density, microarchitecture, and turnover dynamics; when these are compromised, even minor forces can cause fractures. See bone mineral density and osteoporosis for foundational concepts, and bisphosphonates or teriparatide for therapies that modify bone metabolism.

Risk factors

  • Advanced age
  • Female sex (higher prevalence of osteoporosis)
  • Prior fragility fracture, which markedly increases future fracture risk
  • Osteoporosis or low bone mineral density
  • Chronic glucocorticoid use and some other medications
  • Nutritional deficiencies (calcium and vitamin D)
  • Vitamin D deficiency and limited physical activity
  • Smoking and excessive alcohol use
  • Chronic diseases affecting balance, vision, or neuromuscular function
  • Frailty and sarcopenia

Diagnosis

Diagnosing a fragility fracture begins with recognizing a fracture after a low-energy event and confirming the fracture type with imaging. In addition to acute imaging for fracture confirmation, evaluation for underlying bone weakness is common. Bone mineral density testing via dual-energy X-ray absorptiometry (dual-energy X-ray absorptiometry) or newer imaging modalities helps quantify osteoporosis risk, while clinical tools such as the FRAX score FRAX estimate 10-year fracture probability. Vertebral fractures may be subtle on plain radiographs and sometimes require MRI or CT to delineate; fracture risk assessment informs subsequent treatment.

Management

Management has three broad aims: treat the acute fracture, address underlying bone fragility to prevent future fractures, and reduce falls and other risk factors. Management is multidisciplinary, involving orthopedics, geriatrics, rehabilitation, nutrition, and primary care.

  • Acute and surgical management
    • Hip fractures often require surgical repair or replacement, with timing and choice of procedure guided by the patient’s overall health and functional goals. See hip fracture for site-specific approaches.
    • Other fracture sites are managed according to fracture pattern, stability, and patient risk profile; options include internal fixation, vertebral augmentation for certain vertebral fractures, and conservative treatment when appropriate.
  • Analgesia and mobilization
    • Adequate pain control and early mobilization are critical to avoid deconditioning, venous thromboembolism, and pneumonia.
  • Pharmacologic therapy for bone strength
    • Anti-osteoporosis medications are used to reduce the risk of subsequent fragility fractures. These include bisphosphonates, denosumab, and anabolic agents such as teriparatide and abaloparatide. Treatment choice depends on fracture type, fracture risk, kidney function, prior responses, and tolerability.
    • Clinicians monitor for rare but serious adverse events, such as osteonecrosis of the jaw and atypical femoral fracture, and tailor therapy duration accordingly, sometimes using drug holidays after initial response.
  • Rehabilitation and secondary prevention
    • Physical therapy to rebuild strength, balance training to reduce falls, and assisted devices as appropriate are essential to regain function.
    • Nutritional optimization, particularly ensuring adequate calcium and vitamin D intake, supports bone health and muscle function.
    • Secondary prevention programs aim to identify high-risk individuals and coordinate care after an initial fracture to prevent recurrence.

Prevention and public health considerations

Prevention of fragility fractures centers on maintaining bone density, preventing falls, and optimizing nutrition and physical activity. Regular weight-bearing and resistance exercise, fall-risk assessment, home safety adaptations, and treatment of underlying bone disease contribute to reducing fracture risk. Public health strategies include screening guidelines, access to osteoporosis treatment, and affordability of medications. See osteoporosis for the underlying condition most closely linked to fragility fractures and fall prevention for strategies to reduce incident falls.

Controversies and debates

  • Screening and guidelines: There is ongoing discussion about the balance between universal screening for osteoporosis and targeted, risk-based approaches. Proponents of broader screening argue it identifies high-risk individuals earlier, while skeptics cite concerns about cost, overdiagnosis, and patient anxiety. Guidance often emphasizes individualized risk assessment, leveraging tools like FRAX and bone densitometry results to guide treatment decisions.
  • Medication safety and duration: The long-term use of anti-osteoporosis medications raises questions about optimal duration, sequencing, and monitoring for rare adverse events such as osteonecrosis of the jaw and atypical femoral fracture. Some clinicians advocate for finite treatment courses followed by reassessment, while others emphasize sustained therapy in high-risk patients.
  • Resource allocation and policy: Debates exist about how best to allocate resources for fracture prevention, especially in aging populations with rising demand for acute care and rehabilitation services. Proponents of market-based approaches stress innovation and competition in drugs and devices, while critics warn that underinvestment in prevention leads to higher long-term costs due to repeat fractures.
  • Lifestyle versus medicalization: There is discussion about the degree to which public health messaging should emphasize medical therapy versus lifestyle changes. Balancing patient autonomy, evidence on effectiveness, and the costs of broad interventions remains a point of debate in health systems.

See also