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.
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.
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.
Pharmacological treatment is indicated and no feature yet mandates a bone-anabolic specialist sequence.
Key medicines
Alendronic acidTake 70 mg orally once weekly on waking with at least 200 mL plain water, at least 30 minutes before food, drink or another medicine; remain upright for at least 30 minutes.
Zoledronic acidGive 5 mg by intravenous infusion over at least 15 minutes once yearly after hydration and mineral assessment; formally review after three annual doses, extending for persistent high risk.