Fragility Fractures and Osteoporosis
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Direct answer
A fall from standing height that fractures a vertebra, hip, distal radius or proximal humerus defines the fragility fracture — the clinical expression of osteoporosis, a disease of low bone mass and microarchitectural deterioration with bone mineral density T-score of minus 2.5 or below at the spine or hip on dual-energy X-ray absorptiometry (minus 1 to minus 2.5 is osteopenia; the Z-score is used below 50). Every fragility fracture roughly doubles the relative risk of the next, making the first fracture the strongest indication to treat the bone disease rather than merely fix the bone. Treatment couples calcium and vitamin D repletion (Indian context: widespread vitamin D deficiency despite abundant sun, low dietary calcium) with antiresorptives — oral bisphosphonates like alendronate first-line, denosumab, or the anabolic teriparatide for the severest cases — alongside falls assessment and exercise. Surgical care is timely fixation or arthroplasty of hip fractures within 24-48 hours, cement augmentation for painful vertebral fractures failing analgesia, and fracture-liaison-style follow-up.
What you must remember
- Definitions and numbers: osteoporosis T-score at or below minus 2.5 (WHO criterion) at lumbar spine, total hip or femoral neck; osteopenia minus 1 to minus 2.5; fragility fracture from a fall at or below standing height.
- The four typical sites: thoracolumbar vertebral compression, femoral neck and intertrochanteric hip, distal radius (Colles), proximal humerus — any one earns a DEXA and bone workup regardless of age.
- Investigation set: DEXA for diagnosis and monitoring; FRAX integrates risk independent of density (prior fracture, parental hip fracture, steroids, smoking, rheumatoid arthritis); baseline chemistry, thyroid function and 25-hydroxyvitamin D; secondary screens (myeloma, hyperparathyroidism) in atypical presentations.
- Pharmacological ladder: calcium about 1000-1200 mg daily plus cholecalciferol repletion and maintenance; alendronate weekly or zoledronate annually as first-line with correct fasting administration and jaw-osteonecrosis counselling; denosumab six-monthly with rebound-fracture caution if stopped; teriparatide for very high risk, followed by an antiresorptive; drug holidays after 3-5 years in lower-risk responders.
- Hip fracture pathway: surgical fixation within 24-48 hours reduces mortality and complications; arthroplasty for displaced femoral neck fractures in the active elderly; early mobilisation and orthogeriatric co-management are standard.
- Vertebral fracture management: analgesia, early mobilisation; vertebroplasty or kyphoplasty for persistent pain — red flags (young age, fever, weight loss) sent for MRI and biopsy to exclude malignancy and tuberculosis.
- Indian practice numbers: documented widespread vitamin D deficiency despite sunny latitudes, dietary calcium averaging well below recommended, and the common 60,000 IU weekly cholecalciferol sachet repletion course — quotable national context.
A worked case from first fracture to protected skeleton
A 68-year-old postmenopausal woman slips at home and lands on her right palm: a displaced distal radius fracture is reduced and casted, and the event is treated as the sentinel it is. She has no prior fracture, no steroids, modest dietary calcium, and never a DEXA — the fracture itself now qualifies her for bone assessment regardless of what the scan shows. DEXA returns a femoral neck T-score of minus 2.9 and spine minus 2.6; the laboratory screen including myeloma and thyroid is normal; 25-hydroxyvitamin D is 14 ng/mL — the deficiency nearly universal in Indian practice.
Her programme is layered: vitamin D repletion with the weekly high-dose cholecalciferol course then maintenance, dietary counselling toward milk, ragi and green vegetables; alendronate 70 mg weekly with the empty-stomach, upright, water-flush ritual and dental check; weight-bearing and balance exercise and home hazard clearance; and a repeat discussion at three to five years about a drug holiday with DEXA monitoring. Now vary the presentation: her 80-year-old sister with an acute T12 compression on MRI gets analgesia and early mobilisation first, kyphoplasty if pain keeps her bedbound at two to three weeks; and their 82-year-old neighbour with a displaced subcapital femoral neck fracture goes to hemiarthroplasty within 48 hours on an orthogeriatric pathway, with bone treatment beginning on day one.
Where students slip
The first pattern is fixing the fracture and filing the patient: the exam framing is that a fragility fracture is osteoporosis until proven otherwise — treatment thresholds apply even when the T-score sits in osteopenic range, because prior fracture independently raises risk. The second is pharmacology confusion: bisphosphonates are first-line antiresorptives, teriparatide is the anabolic for the highest-risk short course followed by antiresorptive locking-in, and denosumab's discontinuation rebound must be covered — mixing these classes and sequences is the classic error. The third is procedure over-selection: vertebroplasty and kyphoplasty are for painful persistent fractures, not routine first-line management, and neither replaces oncological caution when the history is atypical — in India, alongside metastasis, tuberculosis of the spine is the compression-fracture imitator demanding MRI and biopsy discipline before cement. The vitamin D irony — deficiency at sunny latitudes — is the most quotable Indian-context line in the topic.
Frequently asked questions
What T-score defines osteoporosis on DEXA?
Minus 2.5 or lower at the lumbar spine, total hip or femoral neck; between minus 1 and minus 2.5 is osteopenia, with the Z-score used for premenopausal and younger patients.
Why is a first fragility fracture an indication to treat?
A prior low-energy fracture roughly doubles the risk of the next, independent of density — making the event itself a treatment-grade risk marker and the entry point for DEXA and bone-active therapy.
What is the first-line drug for postmenopausal osteoporosis?
An oral bisphosphonate such as weekly alendronate (or annual intravenous zoledronate) on a foundation of calcium and vitamin D repletion, with correct administration counselling and jaw precautions.
When are vertebroplasty and kyphoplasty indicated?
For painful osteoporotic vertebral compression fractures persisting despite adequate analgesia and mobilisation — kyphoplasty adding height restoration and lower cement leak — after MRI excludes malignancy and infection.
Why is vitamin D deficiency so relevant in Indian osteoporosis?
Deficiency is documented widely across Indian populations despite sunny latitudes, compounded by low dietary calcium — making measurement and repletion standard in every fragility fracture workup.