Synopsis
Recognise fragility fracture as a sentinel event, quantify fracture risk, exclude reversible skeletal disease, begin effective treatment promptly, and plan duration, sequential therapy and safe discontinuation from the outset.
- A fragility fracture follows force equivalent to a fall from standing height or less and should trigger prompt risk assessment and secondary prevention.
- Use FRAX with clinical risk factors; add femoral-neck DXA when it will refine a decision, but do not delay treatment after a recent high-risk fracture merely to await scanning.
- Look for silent vertebral fractures with vertebral-fracture assessment or lateral spine imaging when height loss, kyphosis, acute compatible pain or strong risk warrants it.
- Offer oral alendronate or risedronate, or intravenous zoledronate, to many high-risk adults; choice depends on urgency, adherence, swallowing, renal function, preference and contraindications.
- Denosumab 60 mg subcutaneously every six months must not be delayed or stopped without planned alternative antiresorption; record the next injection and exit strategy before starting.
- Very-high-risk patients, especially after recent or multiple vertebral fractures, need specialist consideration of teriparatide or romosozumab followed promptly by antiresorptive treatment.
- Correct hypocalcaemia and material vitamin-D deficiency, ensure adequate dietary calcium and reduce falls, smoking and excess alcohol; supplements alone do not treat high fracture risk.
- Review oral bisphosphonates around five years and intravenous zoledronate around three, continuing longer when age, fracture history, glucocorticoids or interval fracture maintain high risk.
Key red flags
Sudden hip or groin pain with inability to bear weight after a low-energy fall may be a hip fracture even when initial radiographs are negative and needs urgent definitive imaging.
Acute back pain with progressive weakness, saddle sensory loss, bladder dysfunction or known cancer requires emergency assessment for cord or cauda-equina compression.
Severe focal night pain, weight loss, anaemia, hypercalcaemia or a monoclonal protein suggests myeloma, metastasis or another secondary process rather than uncomplicated osteoporosis.
Jaw pain with exposed bone or new persistent thigh or groin pain during antiresorptive treatment requires assessment for jaw osteonecrosis or atypical femoral fracture.
Investigation priorities
Integrate age and validated clinical factors to decide reassurance, DXA refinement, treatment or specialist referral.
Management branches
A fragility fracture, strong clinical risk profile or opportunistic imaging raises osteoporosis concern.
- Confirm fracture mechanism and site, calculate FRAX where appropriate, assess falls and request DXA only when it will refine rather than postpone the decision.
- Search for vertebral fractures and secondary causes, check renal function, calcium and vitamin D, and address nutrition, smoking, alcohol, strength, balance and home hazards.
- Begin an appropriate anti-fracture medicine promptly after recent fracture, documenting administration, duration review and the response to missed doses or discontinuation.
- Use a fracture liaison service where available to connect acute fracture care, primary-care prescribing, adherence and repeat risk review.
Pharmacological treatment is indicated and no feature yet mandates a bone-anabolic specialist sequence.
- Offer weekly oral alendronate or risedronate when fasting and upright administration is feasible and no important oesophageal or renal contraindication exists.
- Use intravenous zoledronate when adherence, swallowing or absorption makes oral treatment unsuitable, after checking eGFR, calcium, vitamin D and hydration.