AKT · Musculoskeletal/Metabolic bone & tumours

Osteoporosis & fragility fractures

Reduced bone mass/microarchitecture → low-trauma (fragility) fractures

Overview

A skeletal disorder of low bone mass and disrupted microarchitecture that increases fracture risk. It is silent until a fragility fracture (a fracture from a fall from standing height or less) — classically wrist, hip and vertebrae. Risk is assessed with FRAX/QFracture and DEXA; bisphosphonates are first-line treatment. It is the major reason to treat after any fragility fracture.

Recognise

Fragility fracture (low-trauma) — distal radius (Colles), neck of femur, vertebral crush (height loss, kyphosis, back pain)
Risk factors (SHATTERED): Steroids, Hyperthyroid/parathyroid, Alcohol/smoking, Thin (low BMI), Testosterone low, Early menopause, Renal/liver disease, Erosive/inflammatory disease, Dietary low calcium/DM
Often asymptomatic until fracture; DEXA T-score ≤ −2.5 = osteoporosis

Red flags

Vertebral fracture with neurology, or hip fracture → acute orthopaedic/surgical pathway (cross-ref acute_care)
Exclude secondary causes (myeloma, osteomalacia, hyperparathyroidism, metastases) — especially if young or atypical

Differentials & how to tell them apart

Osteomalaciadefective mineralisation — low calcium/phosphate, high ALP, bone pain, Looser zones

Myeloma / bone metastasespathological fractures, raised calcium, lytic lesions, paraprotein

Primary hyperparathyroidismraised calcium and PTH

Investigations

Fracture risk: FRAX or QFracture; DEXA scan (T-score: ≤ −2.5 osteoporosis, −1 to −2.5 osteopenia); bloods to exclude secondary causes (calcium, phosphate, ALP, PTH, vitamin D, TFTs, myeloma screen); X-ray for fractures.

Management

Calcium/vitamin D + alendronate (first-line bisphosphonate); treat after any fragility fracture

1Assess fracture risk (FRAX/QFracture) and DEXA, and exclude secondary causes. Ensure calcium/vitamin D replete, address lifestyle and falls. Start an oral bisphosphonate (alendronate) first-line for those at risk or after a fragility fracture.Gate: Anyone over 50 with a fragility fracture (or on long-term steroids) should be assessed/treated for osteoporosis — fragility fractures are the trigger to act; and counsel bisphosphonate administration (upright, fasting) to avoid oesophagitis.
2Oral bisphosphonate not tolerated → IV zoledronate or denosumab (don't stop denosumab abruptly — rebound fractures); severe/very-high-risk disease → anabolic therapy (teriparatide/romosozumab).

Lifestyle + calcium/vitamin D + falls prevention — foundation; ensure replete before/with antiresorptives

Oral bisphosphonate (alendronate) first-line — taken upright, fasting, with water; risks of oesophagitis, osteonecrosis of the jaw, atypical femoral fracture; IV zoledronate if oral not tolerated

Denosumab — second-line (e.g. renal impairment); do NOT stop abruptly (rebound vertebral fractures)

Teriparatide / romosozumab — anabolic agents for severe/very-high-risk osteoporosis

Key points

A low-trauma (fragility) fracture in the over-50s = osteoporosis until proven otherwise → FRAX/DEXA, calcium/vitamin D, and alendronate first-line. Exclude myeloma/osteomalacia/hyperparathyroidism. Bisphosphonate ritual (upright, fasting); ONJ/atypical-femoral-fracture risks; don't stop denosumab abruptly.

Monitor & prognosis

Fracture incidence, adherence, repeat DEXA, calcium/vitamin D; review bisphosphonate duration (drug holiday).

Treatment substantially reduces fracture risk; hip fracture carries high morbidity/mortality.

Source: NICE CG146 / NOGG; cross-ref endocrine (bone) & acute_care (hip fracture)