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Fragility Fracture – Causes, Symptoms & Treatment
A fragility fracture is a bone break caused by minimal force or impact – typically a sign of reduced bone density, most commonly associated with osteoporosis.
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A fragility fracture is a bone break caused by minimal force or impact – typically a sign of reduced bone density, most commonly associated with osteoporosis.
What Is a Fragility Fracture?
A fragility fracture is a bone fracture that results from mechanical loading that would not normally cause a break in healthy bone. It typically occurs after a fall from standing height or even spontaneously without any significant trauma. Fragility fractures are considered a hallmark sign of osteoporosis – a systemic skeletal disease characterized by reduced bone mass and deterioration of bone microarchitecture.
Causes
The most common underlying cause is osteoporosis, but several risk factors contribute to bone fragility:
- Advanced age (especially from age 65 onwards)
- Female sex and estrogen deficiency after menopause
- Long-term corticosteroid therapy
- Low body weight and nutritional deficiencies (calcium and vitamin D)
- Physical inactivity and immobility
- Smoking and excessive alcohol consumption
- Chronic conditions such as rheumatoid arthritis, chronic kidney disease, or malabsorption syndromes
Common Sites of Fracture
Fragility fractures most often occur at specific skeletal locations:
- Vertebral bodies: Often occurring without dramatic injury, frequently associated with back pain or height loss
- Hip (proximal femur): Associated with significant consequences for mobility and quality of life
- Wrist (distal radius): Common after falling on an outstretched hand
- Proximal humerus (upper arm)
- Pelvis and ribs
Symptoms
Symptoms depend on the location of the fracture and may include:
- Sudden, severe pain at the fracture site
- Swelling, bruising, or visible deformity
- Reduced mobility or inability to bear weight
- In vertebral fractures: gradual back pain, stooped posture (kyphosis), or loss of height
Diagnosis
Diagnosis of a fragility fracture typically involves:
- X-ray imaging: First-line investigation to confirm the fracture
- MRI or CT scan: For suspected vertebral fractures or detailed assessment
- Bone density measurement (DXA scan): To confirm osteoporosis and assess fracture risk
- Laboratory tests: Calcium, vitamin D, bone turnover markers, and exclusion of secondary causes
- FRAX score: An internationally validated tool to calculate the 10-year probability of a major fracture
Treatment
Acute Management
Depending on the location and severity of the fracture, acute treatment may be conservative (immobilization, pain management) or surgical (e.g., hip replacement, vertebroplasty or kyphoplasty for vertebral fractures).
Osteoporosis Treatment
Since a fragility fracture is always an indication of underlying bone fragility, treatment of the root cause is essential:
- Calcium and vitamin D: Basic supplementation to support bone mineralization
- Bisphosphonates (e.g., alendronate, zoledronic acid): Inhibit bone resorption
- Denosumab: A monoclonal antibody that reduces osteoclast activity
- Teriparatide: An anabolic agent that stimulates bone formation
- Romosozumab: A dual-action agent with both anabolic and antiresorptive effects
Rehabilitation and Prevention
Physiotherapy, fall prevention strategies, strength and balance training, and home safety modifications are crucial to reduce the risk of subsequent fractures. After a hip fracture, early mobilization is especially important, as this fracture type is associated with increased mortality.
Prognosis and Clinical Significance
A fragility fracture significantly increases the risk of further fractures. Hip fractures in particular are associated with elevated one-year mortality. Early diagnosis and consistent treatment of the underlying condition are therefore essential for long-term bone health.
References
- Kanis JA et al. – European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporosis International, 2019.
- World Health Organization (WHO): Assessment of osteoporosis at the primary health care level. WHO Press, 2007.
- Compston J et al. – UK clinical guideline for the prevention and treatment of osteoporosis. Archives of Osteoporosis, 2017.
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