What is a Fragility Fracture?
A fragility fracture is a fracture sustained from a fall from standing height or lower that would not cause a fracture in most healthy persons, reflecting compromised bone strength and confirming the presence of skeletal fragility. 1
Core Definition and Mechanism
Fragility fractures (also called "low-energy," "low-trauma," or "osteoporotic" fractures) occur from minimal trauma—specifically, forces equivalent to a fall from standing height or less. 1, 2
These fractures are indicative of compromised bone strength and confirm underlying skeletal fragility, even when bone mineral density (BMD) appears relatively preserved. 1
The fracture itself serves as clinical proof of osteoporosis, regardless of BMD T-score, because most fragility fractures occur in patients with T-scores higher than -2.5. 1
Common Fracture Sites
Major osteoporotic fracture sites include: 1
- Hip
- Spine (vertebral compression fractures)
- Wrist (distal radius)
- Shoulder (proximal humerus)
Additional sites recognized by some authorities include the pelvis, distal femur, proximal tibia, and multiple ribs. 1
Excluded sites that are NOT considered fragility fractures include the face, hands, skull, feet, ankles, fingers, and toes. 1
Clinical Presentation and Recognition
Vertebral compression fractures are the most common fragility fracture type, affecting over 700,000 Americans annually, yet two-thirds are asymptomatic or minimally symptomatic and detected only incidentally on imaging. 3
Many fragility fractures may be clinically silent or present with pain and deformity at the time of injury. 1
Height loss (particularly >4 cm) from vertebral collapse can be a presenting feature. 3
Critical Clinical Significance
A fragility fracture is an important predictor of future fractures and requires immediate evaluation and treatment. 1
Fracture risk is highest in the immediate 1-2 years following a fragility fracture, described as "imminent fracture risk," with approximately 2-fold increased risk of subsequent fractures. 1, 4, 5
Once a vertebral fracture occurs, there is a 20% risk of another vertebral fracture within 12 months. 3
The presence of a fragility fracture confirms skeletal fragility and is itself an indication for pharmacologic treatment, regardless of BMD. 1, 4
Epidemiology and Impact
Worldwide, 1 in 2 women and 1 in 5 men over age 50 will experience a fragility fracture in their remaining lifetime. 1, 3
In 2019, an estimated 178 million new fractures occurred globally, with 455 million people suffering effects of prior fractures. 1, 3
Fragility fractures are associated with significant morbidity and mortality, particularly hip and vertebral fractures, with postfracture mortality highest in the first year. 1, 3
Common Pitfalls in Recognition
Approximately 70% of patients who could benefit from osteoporosis treatment after a fragility fracture do not receive it, representing a major patient care crisis. 1, 4
Most individuals sustaining fragility fractures are not identified as having underlying metabolic bone disease and are not evaluated or treated to reduce future fracture incidence. 1
Normal bone density does not exclude osteoporosis if a fragility fracture has occurred—the fracture itself confirms skeletal fragility even with well-maintained BMD. 1, 3
Most vertebral fractures do not present with pain, requiring dedicated vertebral imaging for detection in high-risk patients. 1