Synopsis
Recognise a fragility fracture as both an acute mechanical injury and a sentinel event, then combine safe orthopaedic treatment with prompt investigation and secondary fracture prevention.
- A fragility fracture follows force no greater than a fall from standing height and is a treatment trigger, not a reason to postpone prevention until DXA.
- First-line orthopaedic assessment addresses the current fracture: mechanism, pre-injury function, pain, skin, distal neurovascular status, imaging in two planes and safe loading instructions.
- Use FRAX for ten-year probability and add femoral-neck DXA when the result will alter treatment; a recent hip or vertebral fracture already establishes high risk.
- Look actively for silent vertebral fractures when there is height loss, kyphosis, glucocorticoid exposure or suspicious spinal pain because they markedly change future risk.
- Start secondary prevention promptly through a fracture liaison service while fracture care continues; avoid leaving the decision to an unspecified future primary-care review.
- Oral alendronic acid or risedronate and intravenous zoledronic acid are usual first-line antiresorptive options; post-hip-fracture zoledronate is especially useful when oral adherence is doubtful.
- Very-high-risk features such as a recent vertebral fracture, multiple vertebral fractures or extremely low BMD warrant specialist consideration of anabolic-first treatment followed by antiresorptive consolidation.
- Never delay or stop denosumab without a documented next dose or sequential antiresorptive plan because rebound turnover can cause multiple vertebral fractures.
Key red flags
A painful deformed limb, inability to bear weight after trivial trauma or focal bony tenderness in an older adult may be a fracture even when bruising is slight.
A shortened externally rotated leg after a fall is a hip fracture until imaging proves otherwise; provide analgesia and follow the urgent hip-fracture pathway.
Sudden spinal pain with weakness, sensory level, saddle numbness or sphincter change requires immediate immobilisation decisions and emergency MRI assessment.
Multiple fractures, lytic change, hypercalcaemia, weight loss, anaemia or pain unrelated to movement suggests malignancy or myeloma rather than uncomplicated primary osteoporosis.
Atypical subtrochanteric or femoral-shaft pain during prolonged antiresorptive therapy requires bilateral femoral imaging and protected loading before a complete fracture occurs.
Jaw pain, exposed bone or an unhealed extraction site during potent antiresorptive treatment warrants dental or maxillofacial assessment without unplanned medicine cessation.
Investigation priorities
Define location, displacement, articular involvement, bone texture and any destructive feature before loading or reduction decisions.
Management branches
A low-energy injury produces focal pain, deformity or loss of weight-bearing ability.
- Use ABCDE when indicated, provide analgesia and document skin, compartments and distal neurovascular findings.
- Immobilise the painful region and restrict loading until radiographs and orthopaedic review establish stability.
- Escalate open injury, threatened skin, hip fracture, neurological deficit and unstable vertebral features through emergency pathways.
- If hip-fracture suspicion persists after normal films, obtain MRI promptly or CT when MRI is unavailable within 24 hours or contraindicated.