Osteoporosis and Fractures — A Hollowed Pillar and the Moment of the Fall

A Hand Caught in the Kitchen

My mother, past seventy, slipped on the kitchen floor and caught herself with her hand. Her wrist swelled up, and when she went to the hospital, the wrist bone was broken. The doctor who put on the cast suggested having a bone check-up. It was not a fall from a height, just a single slip, so why look at the bones?

The disease often lying behind this scene is osteoporosis. Among people over fifty, one in three women and one in five men breaks a bone because of this disease at least once in their lifetime (PMID 40587168). This kind of breakage begins to increase noticeably around age fifty-five for women and sixty-five for men (PMID 30696576). This disease neither hurts nor shows on the outside until a bone breaks.

Osteoporosis is a condition where the amount of bone decreases and the inner structure becomes sparse, making it easy to break from a small impact. Think of an old wooden pillar, and it is like this. A pillar whose exterior looks the same while the material filling the inside has emptied out and the inner braces have thinned stands completely fine under normal circumstances. The moment that pillar breaks is when someone pushes hard or the pillar itself tumbles.

This article looks in turn at the test that measures how porous the inside of the pillar has become, what those numbers miss, the moment that knocks the pillar down, and how to prevent both together.

When the Demolition Side Gets Ahead

Bone is a tissue that is remodeled throughout life. Bone remodeling is the process of slightly dismantling old bone and filling that space with new bone, which continues throughout the skeleton for a lifetime. How this process runs is followed in "How Bone Is Alive — A Construction Site That Tears Down While Building, A Material Warehouse You Draw From". When days where the amount dismantled is greater than the amount filled accumulate for a long time, the bones shrink little by little.

In women, the decrease in estrogen after menopause is the biggest cause of bone loss (PMID 34448749). A hip fracture is a break just below the hip joint, in the upper part of the thigh bone. The reason this fracture is more common in women is also because bones are lost faster after menopause and falling happens more frequently (PMID 42461643).

Several factors raise the risk. The older you are, the more female you are, and the lower your body weight, the greater the risk. Having broken a bone or fallen before, and having a parent who has broken a hip, also raise the risk. Taking steroid medications for a long time, smoking and excessive alcohol, and diseases like rheumatoid arthritis or chronic liver and kidney disease are also on the list (PMID 40587168). The fact that "having fallen before" is on this list becomes important again later in this article.

This disease is known as a women's disease, but about 40% of fractures caused by osteoporosis occur in men (PMID 36382763). Male osteoporosis comes from identifiable causes such as sex hormone deficiency, excessive alcohol, or steroid medications in up to half of the cases (PMID 36382763).

The pillar metaphor breaks down here once. A wooden pillar does not fix itself, but bone is dismantled and rebuilt throughout life. Thanks to that, there is room for drugs that slow down the demolition side or help the building side to do their work.

What a Bone Density Test Measures

The result sheet of a bone test from a health checkup or hospital usually has a few numbers on it. Bone mineral density is a value measured by shining X-rays on a bone to see how much minerals are in that area, and is a representative number used to gauge the amount of bone. DXA is a test that measures bone mineral density by shining two X-ray beams of different intensities onto the body, commonly called a bone density test. It involves low radiation and is widely used, making it the most common way to gauge fracture risk (PMID 28716497). The sites usually measured are the lumbar spine and the hip (PMID 24577348).

The T-score is a number counting how far your bone density falls from the average of healthy young adults, using the standard deviation—the width of typical differences among people—as a single unit. A score of 0 means it is the same as the young adult average, and −1 means it is one step lower than that.

The World Health Organization (WHO) defined osteoporosis using the T-score, and this definition placed the bone density test at the center of diagnosis (PMID 28716497). The World Health Organization criteria consider bone mineral density that is lower than the young adult average by 2.5 standard deviations or more—in other words, a T-score of −2.5 or lower—to be osteoporosis (PMID 12057569). Osteopenia is the name given in the World Health Organization classification to the range where bone mineral density is lower than the young adult average by 1 standard deviation or more, but falls short of the osteoporosis criteria (PMID 42461643). These criteria are for women around or after menopause and men aged 50 and older, and results for younger people are read with a different yardstick (PMID 38107823).

The lower the bone density, the higher the fracture risk. Every time bone mineral density drops by one standard deviation, the fracture risk becomes 1.5 to 2.5 times higher (PMID 28716497). This is a strength similar to how well blood pressure predicts myocardial infarction (PMID 28716497).

Even so, the line is a guideline drawn for diagnosis. If you judge for yourself whether you have a disease based on a single number on your report sheet, you drift away from the fracture risk assessment that this test was originally meant to do. How to read that number is decided in consultation along with age, fracture history, and other risk factors (PMID 39803994).

What Numbers Cannot Measure

Between two people with the exact same T-score, only one might experience a fracture. The bone mineral density of people who will experience a future fracture and those who will not overlaps to a large extent (PMID 28716497). The numbers can also fluctuate due to poor posture, arthritis, previously fractured bones, or jewelry captured in the scan (PMID 28716497).

There are also factors independent of bone mineral density that increase risk. These include age, a prior fracture from minor trauma, early menopause, a history of hip fracture in parents, and taking oral steroid medications (PMID 12057569). Among them, the fact of having suffered a prior fracture carries particularly heavy weight. In an analysis tracking approximately 2.1 million people across 64 cohorts in 32 countries, individuals who had experienced a fracture had about a 1.9-fold risk of experiencing any subsequent fracture, with no difference between men and women (PMID 37566158). The fraction of this risk explained by low bone mineral density was only 14% for any fracture and 33% for hip fracture (PMID 37566158).

A fracture risk assessment tool is a calculation formula that combines bone mineral density with risk factors such as age, sex, prior fracture, and parental hip fracture to estimate the probability of a major fracture within the next 10 years. FRAX is the most representative of these, in which major fractures bundle together hip, spine, upper arm, and wrist fractures (PMID 38107823). However, the ability of bone mineral density alone, or of such tools, to screen out fractures has generally been low to moderate (PMID 39808441). Even so, guidelines in many countries have shifted toward deciding treatment by looking at overall fracture risk rather than a single T-score (PMID 37816527; PMID 39803994; PMID 38809256).

The door to diagnosis has also widened. An expert working group in the United States proposed that postmenopausal women and men aged 50 and older should be diagnosed with osteoporosis if they have experienced a hip fracture, have a fracture in the spine, upper arm, pelvis, or in some cases the wrist while in the osteopenic range, or have a high probability on a fracture risk assessment tool, even if their T-score is higher than −2.5 (PMID 24577348). Another review similarly advises diagnosing based on actual fractures that have occurred rather than relying solely on bone mineral density testing (PMID 33523422).

Bone mineral density is a number that serves as a proxy measurement for bone fracture. Whether a better number always means fewer fractures is explored in "Better Numbers, Better Patients? — An Introduction to Surrogate Endpoints". Because bone mineral density is just one piece of fracture risk, the risk remains even if the number is above the baseline, provided there is a history of prior fracture or other risk factors. Conversely, a low number does not mean that a person will immediately fracture.

Three Sites That Break

Among the four major fractures seen earlier, the three sites this article follows are the wrist, spine, and hip. The wrist was already seen through the mother in the kitchen. A fragility fracture is when a bone breaks from a minor impact that a healthy bone would have withstood. A fall from a standing height is a typical example.

A vertebral compression fracture is a fracture where the body of a vertebra is pressed from above and below, collapsing flat. It is the most common among osteoporotic fractures (PMID 32967415). Yet it is the easiest to miss. More than two out of three have no symptoms, so they are discovered incidentally on X-rays taken for other reasons (PMID 27386723). Roughly two-thirds of the vertebral compression fractures that occur each year go undiagnosed and do not lead to treatment (PMID 32967415).

When there are symptoms, there can be sudden back pain when changing posture, coughing or sneezing, or lifting something (PMID 27386723). Over time, it can lead to a loss of height, a rounded back, persistent pain, and difficulties with daily life (PMID 27386723). When measuring bone mineral density, the same machine is sometimes used to take a side view of the spine to find hidden fractures, and if an unknown spinal fracture appears, the diagnosis, risk assessment, and treatment plan can change (PMID 28729044). Having this fracture also substantially increases the risk of subsequent fractures (PMID 32967415).

Hip fractures are experienced by more than 14.2 million people worldwide each year, and they most commonly occur after a fall (PMID 42461643).

One Year After a Hip Fracture

Among people who experience a hip fracture, the median proportion who die within one year across various studies is 22% (PMID 42461643). Even now that surgeries have improved, the one-year mortality rate is reported to be 15 to 30% (PMID 40700118).

This number also includes the toll on bodies that were already frail before the fracture. A hip fracture is seen as both revealing an already weakened body and accelerating that fragility (PMID 40700118). Recovery also varies from person to person. The proportion of people who regain their pre-fracture level of basic daily activities, such as bathing and dressing, within 6 months is 42 to 71% (PMID 42461643), and fewer than half of the survivors recover their full pre-fracture function (PMID 40700118).

Surgery usually involves replacing the joint or mending the bone with metal fixations, which is then followed by rehabilitation therapy, measures to reduce falls, and medications to prevent the next fracture (PMID 42461643). Patients who got up and moved early after surgery had fewer deaths and complications within 30 days. This is an analysis pooling multiple studies, and whether early movement is the direct cause has not yet been proven (PMID 38353351). The process of recovering function is covered in "Rehabilitation — Starting to Plan a Livable Home as the Fire Is Brought Under Control".

When an older person falls and experiences pain in the hip or groin so that they cannot stand or bear weight on the leg, it is a representative sign suspecting a hip fracture, prompting immediate medical evaluation. This is because early surgery is emphasized for helping recovery (PMID 40700118). Whether it is a fracture cannot be distinguished by symptoms alone, and is confirmed through physical examination and imaging such as X-rays.

The Moment the Pillar Is Pushed

More than one in four adults over the age of sixty-five fall every year (PMID 38536167). A fall is an unintentional event of falling or dropping to the floor or a lower level. At this age, falls are the leading cause of injury-related death (PMID 38536167). One review notes that a fracture occurs in roughly one out of every ten falls (PMID 35055695).

There are reasons why people fall. Shaky gait and balance, a drop in blood pressure when standing up, poor vision and hearing, medications, and household hazards are cited as modifiable risk factors (PMID 38536167). Weak leg muscles and poor eyesight also appear on the list of risk factors for hip fractures (PMID 42461643). Sarcopenia is a condition in which muscle mass, strength, and function all decrease together with aging, is linked to more frequent falls and fractures, and is a topic this series will cover in the future (PMID 30993881).

Let us return to our mother in the kitchen. At that exact moment of slipping, two things overlapped. One was how porous the inside of her bones had become, and the other was why she slipped. A bone density test measures only the former. On the list of hip fracture risk factors, low bone density and previous fractures sit alongside things that cause falls, such as muscle strength and vision (PMID 42461643).

One review advises that fractures in older adults should not be viewed as bad-luck accidents, but accepted as predicted outcomes of underlying osteoporosis (PMID 33523422). Falls are likewise not purely a matter of luck; they have modifiable causes attached to them (PMID 38536167). Many fractures, especially hip fractures, occur at the intersection where weakened bones and the moment of a fall meet (PMID 42461643). Therefore, preventing fractures involves both medications to protect the bone and efforts to reduce the risk of falling (PMID 34448749).

There is one more place where the pillar analogy does not fit. A vertebral compression fracture can occur without a fall, simply from twisting the body or lifting something (PMID 27386723).

The Evidence for Reducing Falls

In an analysis pooling 59 randomized trials involving about 13,000 adults aged 60 and older living in the community, exercise reduced the number of falls by 23% (PMID 30703272). Compared to a group where 1,000 people fell 850 times over a year, the exercise group fell about 195 fewer times (PMID 30703272). The number of people who fell at least once decreased by 15%, and the certainty of evidence for both results was high (PMID 30703272). Participants averaged 76 years of age, and 77% were women (PMID 30703272).

The effect was clear in programs that practiced balance and everyday movements. Programs consisting only of strength training, or only of dancing or walking, had uncertain effects on falls (PMID 30703272). Programs that challenged balance more difficultly and had a higher volume showed greater effects (PMID 27707740). Adverse events were poorly reported, but those reported were mostly rare and mild muscle and joint symptoms (PMID 38833257).

The evidence that exercise reduces fractures as well is weaker. In the same analysis, the number of people who suffered fractures from falls leaned toward a reduction, but the certainty was low (PMID 30703272). An analysis linking and comparing 192 studies also associated exercise with fewer fractures caused by falls (PMID 34318929). A review for the US Preventive Services Task Force (USPSTF) found that exercise reduced falls and injurious falls (PMID 38833257).

There are also groups where the effect has not been confirmed. In people living in nursing facilities, those who have suffered a stroke, and those recently discharged from the hospital, there was no evidence that exercise alone reduced falls, and the authors noted that these groups require further research (PMID 27707740).

There are other paths besides exercise. Cataract surgery was associated with fewer falls, as was modifying the home environments of high-risk individuals (PMID 38536167). Programs solely focused on stopping medications that increase fall risk did not confirm a clear reduction, but such actions were commonly included in multi-component programs that showed effects (PMID 38536167). Methods that identified and corrected multiple risk factors all at once reduced the number of falls, but evidence showing they reduced fractures did not emerge (PMID 38833257).

The evidence that exercise reduces falls is solid, while the evidence on whether that exercise also reduces fractures is still weak.

Bone-Protecting Medications: Two Paths

Osteoporosis medications are broadly divided into two paths (PMID 41252575). Antiresorptives are a class of drugs that slow down the bone-demolishing side, helping prevent bone from escaping. Bisphosphonates are the representative class (PMID 40587168). Bone-building agents are a class of drugs that encourage the side that builds new bone, adding to the bone. Compared to a pillar, the former stops the inside from hollowing out further, while the latter adds new material to the inside.

In people at high risk of fracture, antiresorptives reduce vertebral fractures by about 52 cases and hip fractures by about 6 cases per 1,000 people followed for a year (PMID 40587168). How the numbers of a percentage reduction and a fewer number of broken bones differ is covered by "If the Risk Was Cut in Half, How Many Fewer People Got Sick? — Relative and Absolute Risk".

It takes time for medications to produce benefits. In an analysis pooling randomized trials involving postmenopausal women with osteoporosis, it took an average of about 12.4 months for 100 people using bisphosphonate-class drugs to prevent 1 non-vertebral fracture (PMID 34807231). The authors wrote that these drugs are most likely to provide a benefit to people whose remaining life expectancy is longer than 12.4. months (PMID 34807231).

Guidelines make different recommendations depending on the target population. The American College of Physicians (ACP) strongly recommends the bisphosphonate class as the initial medication for postmenopausal women with osteoporosis, while issuing a conditional recommendation of lower certainty of evidence for men (PMID 36592456). For individuals at very high fracture risk, such as those who recently suffered a spinal fracture, a review notes that considering bone-building agents first followed by antiresorptives is an approach to consider (PMID 40587168), and a European expert working group (ESCEO) also supports this sequence (PMID 35332506).

Medications also have rare side effects. Using the bisphosphonate class for more than 3 years can increase the risk of osteonecrosis of the jaw, where a part of the jawbone dies, and atypical fractures where the shaft of the thighbone breaks in an unusual way, but their absolute risk was low, and in the same review these drugs reduced hip and vertebral fractures in postmenopausal women with osteoporosis (PMID 36592455). Among bone-building agents, some reduced vertebral fractures, but more people stopped taking them due to side effects (PMID 36592455). In a review for the US Preventive Services Task Force, treatment spanning several years was associated with a reduction in fractures, and side effects did not increase meaningfully (PMID 39808441). A review views that in people at high risk of fracture, the benefits are likely to outweigh the harms for up to 10 years (PMID 30696576).

Medications require a plan even when stopping them. With one of the injectable antiresorptives, if a long-term user stops without a follow-up medication or misses and delays an injection, bone demolition can suddenly surge (PMID 39448137). One review summarizes that about 1 in every 14 people who stopped this drug without a subsequent medication developed multiple vertebral fractures (PMID 39448137). Transitioning to another medication after finishing this drug significantly reduces this risk (PMID 39448137).

The magnitude to which calcium and vitamin D supplements reduce fractures is small. In an analysis pooling adults not taking osteoporosis medications, most of whom were not at high risk for fractures or falls, the authors concluded that calcium, vitamin D, and using both together had almost no benefit in preventing fractures and falls (PMID 42161415). Evidence regarding high-risk individuals and nursing home residents was sparse (PMID 42161415). In another analysis, vitamin D alone did not reduce fractures, and fractures were slightly fewer in the group that used it together with calcium (PMID 31860103). The earlier analysis also showed slightly fewer fractures in the combined group, but judged that the magnitude could not be considered meaningful (PMID 42161415).

Calcium and vitamin D intake, including from food, is recommended to be adjusted appropriately according to guidelines (PMID 40587168).

Even with these medications available, many people do not use them. In Germany, 71% of individuals with osteoporosis are untreated (PMID 39803994). Evidence that medications reduce fractures has accumulated, and while rare side effects do occur, it is considered that the benefits outweigh the harms in people at high fracture risk.

Once Broken

Here is why the doctor recommended a bone scan for your mother with a broken wrist. Imminent fracture risk refers to the fact that the risk of a subsequent fracture spikes significantly during the first 1 to 2 years after an initial fracture, especially in the very first few months. This risk is highest within 3 to 6 months after the injury (PMID 42444566).

In an analysis combining observational studies following people aged 50 and older, 1 in 10 people (11.58%) broke a bone again within 2 years after a fragility fracture (PMID 35776148). About half of these re-fractures happened within the first 2 years (PMID 35776148). This rate is an average and varied by region (PMID 35776148).

There is a mismatch of time here. Osteoporosis medications usually take 6 to 12 months to become effective, which is precisely when re-fractures are most frequent (PMID 30368717). This is why guidelines recommend prompt evaluation and treatment following a fracture (PMID 30368717; PMID 35776148). Getting patients moving early after a fracture, evaluating fall risks, and starting bone-protecting medications are cited as milestones to prevent the next fracture (PMID 39613909).

A fracture liaison service is a care program that connects fracture treatment at the hospital to osteoporosis evaluation and treatment. Among patients who received this service, the rate of starting and continuing medication was 38%, compared to 17% for those who did not (PMID 40587168). This difference is believed to reduce subsequent fractures (PMID 40587168).

Even if your mother's T-score comes out higher than −2.5, the story does not end. As we saw earlier, the weight of a prior fracture is not fully explained by bone density, and the aforementioned U.S. working group proposed using wrist fractures occurring in the osteopenia range as a basis for diagnosing osteoporosis in certain cases (PMID 24577348). What treatment to pursue is decided through a risk assessment that incorporates that fracture alongside other risk factors (PMID 37816527).

The story is the same even if your father suffered a fracture. The degree to which the risk of a subsequent fracture rises after an initial fracture was similar between men and women (PMID 37566158), and the risk of re-fracture was actually slightly higher in women (PMID 35776148). One review notes that the risk of death after a first fracture is higher in men (PMID 36382763). Yet, only 10% of men with osteoporosis receive appropriate treatment (PMID 36382763).

Screening for individuals who have not yet broken a bone is a different situation. For people with no diagnosis of osteoporosis and no history of fragility fractures, the U.S. Preventive Services Task Force recommends osteoporosis screening for women aged 65 and older and younger postmenopausal women at increased risk (PMID 39808425). The same body stated that there is insufficient evidence to determine the benefits and harms of screening for men (PMID 39808425). Insufficient evidence does not mean that male osteoporosis is rare.

Where to Look Further

The process of bones being torn down and rebuilt throughout a lifetime is followed from the beginning in "How Bones Stay Alive — A Demolition Site and a Reusable Material Warehouse".

How well a number like bone mineral density can stand in for fractures is picked up by "Better Numbers, Better Patients? — An Introduction to Surrogate Endpoints", and how to read the effects of a drug in percentages and numbers of people is taken over by "If the Risk Was Cut in Half, How Few People Got Sick? — Relative and Absolute Risk". What test numbers tell us among people with overlapping results is covered by "What a Test Actually Tells You — An Introduction to Sensitivity, Specificity, and Pretest Probability", and recovering function after a hip fracture is handled by "Rehabilitation — Starting to Plan a Livable Home as the Fire Is Brought Under Control".

How to sequence various drugs across a lifetime remains an unresolved question, aside from the order of bone-forming agents followed by bone-resorption inhibitors (PMID 36382762).

Source Papers

• "Osteoporosis: A Review." (2025) — PMID 40587168 — Lifetime osteoporosis fracture in 1 in 3 women and 1 in 5 men aged 50 and older, risk factors, fracture risk assessment algorithms, T-score of −2.5 or lower, bone resorption inhibitors in the high-risk group showing spine −52 and hip −6 per 1,000 patient-years, bone formation stimulators followed by bone resorption inhibitors in the very high-risk group, and fracture liaison services at 38% versus 17%.
• "Osteoporosis." (2019) — PMID 30696576 — Fractures increase after age 55 in women and 65 in men, long-term management as a chronic disease, a favorable benefit-risk balance of up to 10 years of treatment in high-risk groups, and treatment gaps.
• "The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group." (2014) — PMID 24577348 — Proposed as a basis for diagnosis based on hip fracture, spine, humerus, pelvis, and some wrist fractures in osteopenia, and high FRAX risk, in addition to T-scores (lumbar spine, femoral neck, total hip).
• "Hip Fractures: A Review." (2026) — PMID 42461643 — 14.2 million cases per year, low bone mineral density defined as 1 SD or more below young adults, a median 1-year mortality rate of 22%, 26.9% for men and 18.5% for women in the United States from 2008 to 2017, recovery of basic daily activities within 6 months at 42 to 71%, mostly following a fall, risk factors (muscle strength, vision, etc.), surgery, rehabilitation, fall reduction, and medication.
• "Imminent fracture risk: contributing mechanisms, risk assessment, and implications for treatment." (2026) — PMID 42444566 — The risk of a subsequent fracture rises 12 to 24 months after the first fracture, peaking in the first 3 to 6 months.
• "Clinical Practice Guideline: The Diagnosis and Treatment of Osteoporosis." (2025) — PMID 39803994 — German guidelines, risk factor assessment as the basis of diagnosis, step-by-step evaluation, and 71% of German osteoporosis patients untreated.
• "Sentinel fracture: the necessity of improved post-fracture care." (2025) — PMID 39613909 — Early mobilization, fall risk assessment, and initiating medication as milestones in preventing the next fracture, and fracture liaison services.
• "Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults: A Review." (2024) — PMID 38536167 — Over 25% of people aged 65 and older fall annually, the top cause of injury-related death, modifiable risk factors, cataract surgery and environmental improvements linked to reductions, while medication cessation programs alone show no significant reduction.
• "Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force." (2024) — PMID 38833257 — Multifactorial interventions reduce falls but not fractures, exercise reduces falls and injurious falls, and harms are rare and mild.
• "Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians." (2023) — PMID 36592456 — Bisphosphonates as first-line therapy for postmenopausal women (strong recommendation, high certainty) and conditional for men (low certainty).
• "Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update." (2023) — PMID 37816527 — Management depends on fracture risk assessed using validated tools, with individualized exercise, nutrition, and medication.
• "Male osteoporosis." (2022) — PMID 36382763 — Narrative review noting that about 40% of fractures occur in men, the risk of death after a first fracture is higher in men, appropriate treatment stands at 10%, and up to half have secondary causes.
• "The why and how of sequential and combination therapy in osteoporosis. A review of the current evidence." (2022) — PMID 36382762 — How to sequence different treatments remains unclear, with bone formation stimulators followed by bone resorption inhibitors specifically considered for high-risk patients with imminent risk.
• "The imminent risk of a fracture-existing worldwide data: a systematic review and meta-analysis." (2022) — PMID 35776148 — 19 observational studies, aged 50 and older, subsequent fracture at 1 year at 7.58% and 2 years at 11.58%, half of subsequent fractures occurring in the first 2 years, Asia at 7.30%, Europe/North America at 13.17%, and slightly higher in women (HR 1.18).
• "Vertebral compression fractures: Still an unpredictable aspect of osteoporosis." (2021) — PMID 32967415 — Vertebral compression fractures as the most common fragility fracture, substantial additional fracture risk, and about two-thirds undiagnosed and untreated.
• "Interventions for preventing falls and fall-related fractures in community-dwelling older adults: A systematic review and network meta-analysis." (2021) — PMID 34318929 — Network meta-analysis of 192 studies, with exercise linked to a reduction in fall-related fractures.
• "Exercise for preventing falls in older people living in the community." (2019) — PMID 30703272 — Cochrane review, exercise reducing the fall rate by 23% and fallers by 15% (high certainty), focusing on balance and functional exercises, with low certainty for reducing fall fractures, and uncertainty for strength, dance, or walking alone.
• "Sarcopenia and its association with falls and fractures in older adults: A systematic review and meta-analysis." (2019) — PMID 30993881 — Association of sarcopenia with increased risk of falls and fractures.
• "Importance of Recent Fracture as Predictor of Imminent Fracture Risk." (2018) — PMID 30368717 — Type and timing of a previous fracture determining risk largely independently of bone mineral density, 6 to 12 months until medication takes effect, during which refractures are most frequent.
• "Dual-energy X-ray Absorptiometry." (2017) — PMID 28716497 — Bone mineral density and T-score using two X-ray energies, WHO 1994 definition, relative risk per standard deviation of 1.5 to 2.5, overlap in bone mineral density between those with and without fractures, and positioning errors or artifacts.
• "The Clinical Utility of Vertebral Fracture Assessment in Predicting Fractures." (2017) — PMID 28729044 — Most vertebral fractures are clinically unrecognized, and vertebral fracture assessment during bone mineral density measurement can alter diagnosis, risk, and treatment.
• "Exercise to prevent falls in older adults: an updated systematic review and meta-analysis." (2017) — PMID 27707740 — Greater effect with challenging balance and high-dose exercise, and no evidence of effect in residential care, stroke survivors, or recent hospital dischargees.
• "Diagnosis and Management of Vertebral Compression Fractures." (2016) — PMID 27386723 — Over two-thirds asymptomatic and found incidentally, acute pain with posture change, coughing, or lifting, and chronic pain, loss of height, and functional impairment.
• "Diagnosis of osteoporosis and assessment of fracture risk." (2002) — PMID 12057569 — Osteoporosis defined as bone mineral density 2.5 standard deviations or more below the premenopausal female average, and risk factors independent of bone mineral density.
• "Recent Advances in Osteoporosis Therapeutics." (2026) — PMID 41252575 — Treatments divided into antiresorptive therapy and bone-forming therapy.
• "Time to Benefit of Bisphosphonate Therapy for the Prevention of Fractures Among Postmenopausal Women With Osteoporosis: A Meta-analysis of Randomized Clinical Trials." (2022) — PMID 34807231 — 10 randomized trials involving 23,384 people, 12.4 months to prevent 1 non-vertebral fracture per 100 people, 200 people over 20.3 months for 1 hip fracture, and potential benefit when life expectancy exceeds 12.4 months.
• "Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement." (2025) — PMID 39808425 — Screening recommended for women aged 65 and older and postmenopausal women under 65 at high risk, with insufficient evidence for men.
• "Hip Fracture as a Systemic Disease in Older Adults: A Narrative Review on Multisystem Implications and Management." (2025) — PMID 40700118 — 1-year mortality of 15 to 30%, fewer than half of survivors recovering pre-fracture function, a systemic event reflecting and accelerating frailty, and an emphasis on early surgery.
• "Screening for Osteoporosis to Prevent Fractures: A Systematic Evidence Review for the US Preventive Services Task Force." (2025) — PMID 39808441 — Risk assessment tools and bone mineral density having low to moderate discrimination, multi-year treatment linked to reduced fractures without a meaningful increase in adverse effects.
• "Update on fracture risk assessment in osteoporosis." (2024) — PMID 38809256 — Limitations of simply using a previous fracture or baseline T-score, and an approach determining treatment targets based on fracture probability.
• "Classification of Osteoporosis." (2023) — PMID 38107823 — WHO T-score classification targeting the perimenopausal and postmenopausal transition and women and men aged 50 and older, different criteria for younger individuals, and FRAX major fractures comprising hip, spine, humerus, and wrist.
• "Previous fracture and subsequent fracture risk: a meta-analysis to update FRAX." (2023) — PMID 37566158 — 64 cohorts across 32 countries, previous fracture HR 1.88, no difference between sexes, and 14% of the share explained by low bone mineral density (33% for hip).
• "Effectiveness and Safety of Treatments to Prevent Fractures in People With Low Bone Mass or Primary Osteoporosis: A Living Systematic Review and Network Meta-analysis for the American College of Physicians." (2023) — PMID 36592455 — Bisphosphonates and denosumab reducing fractures in postmenopausal women with osteoporosis, bisphosphonates for 36 months or longer potentially increasing the risk of atypical femoral fracture and osteonecrosis of the jaw but with low absolute risk, and bone formation stimulators increasing discontinuation due to adverse effects.
• "A Review on Aging, Sarcopenia, Falls, and Resistance Training in Community-Dwelling Older Adults." (2022) — PMID 35055695 — Narrative review stating one fracture per ten falls.
• "Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society." (2021) — PMID 34448749 — Postmenopausal bone loss due to estrogen deficiency as the primary cause, combining non-pharmacological measures, medications, and fall risk reduction strategies.
• "Management of patients at very high risk of osteoporotic fractures through sequential treatments." (2022) — PMID 35332506 — European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) position statement, recommending bone formation stimulators first followed by maintenance with bone resorption inhibitors in patients at very high fracture risk.
• "Approaches to Fracture Risk Assessment and Prevention." (2021) — PMID 33523422 — Framing fractures not as unfortunate accidents but as predictable outcomes of osteoporosis, diagnosing via clinical fractures rather than relying solely on bone mineral density.
• "Calcium, vitamin D, or combined supplementation to prevent fractures and falls: systematic review and meta-analysis." (2026) — PMID 42161415 — 69 trials involving 153,902 people (mostly community-dwelling, not high risk, not using osteoporosis medication), showing little effect on fractures and falls, with limited evidence for high-risk and residential care settings.
• "Vitamin D and Calcium for the Prevention of Fracture: A Systematic Review and Meta-analysis." (2019) — PMID 31860103 — Vitamin D alone showing no fracture reduction, while combined vitamin D and calcium reduces all fractures by 6% and hip fractures by 16%.
• "Early mobilisation after hip fracture surgery is associated with improved patient outcomes: A systematic review and meta-analysis." (2024) — PMID 38353351 — 13 studies involving 297,435 people, early mobilization linked to reduced 30-day mortality and complications, causality unproven.
• "Prevention and Management of Denosumab Discontinuation Rebound Fractures." (2024) — PMID 39448137 — Rebound fractures (multiple) in about 1 in 14 people when discontinued without follow-up antiresorptive treatment, greatly reduced by follow-up treatment.