A broken bone after a hard collision, a major fall, or a car accident makes sense. A fracture after tripping on a rug, stepping off a curb, or falling from standing height is different. In an adult over 50, that type of injury may be a fragility fracture, an important warning that the bone was not as strong as it should have been.
From an orthopedic perspective, treating the fracture is only half the job. The next question is just as important:
Why did this bone break, and what can we do to prevent the next fracture?
Osteoporosis is often called a silent disease because bone loss usually does not hurt. For many people, the first obvious sign is a broken wrist, hip, shoulder, pelvis, or vertebra after a relatively minor event. The good news is that osteoporosis can be evaluated and treated, even after a fracture has already occurred.
What is a fragility fracture?
A fragility fracture is a bone break caused by low-energy trauma, commonly a fall from standing height or lower. The same event would not normally be expected to break healthy bone.
Common fragility fractures involve the:
- Wrist, especially the distal radius
- Hip, including the femoral neck and intertrochanteric region
- Spine, where a vertebra may compress or collapse
- Shoulder, especially the proximal humerus
- Pelvis
Not every fracture after a fall is caused by osteoporosis. The direction of the fall, the surface, body weight, speed, and the way a person lands all matter. Still, a low-energy fracture in an adult over 50 should usually prompt a bone-health discussion rather than being dismissed as simple bad luck.
Why can a small fall break a weakened bone?
Bone is living tissue. It is constantly being removed and rebuilt. With aging, menopause, certain medications, chronic disease, inactivity, low body weight, and other risk factors, bone breakdown can begin to outpace bone formation.
Bone strength depends on more than the amount of calcium in the skeleton. It also depends on:
- Bone density
- Cortical thickness, which is the strong outer shell
- Trabecular structure, the internal supporting network
- Bone turnover and tissue quality
- Muscle strength, balance, and fall risk
This is why a person can fracture even when a bone-density test is not in the classic osteoporosis range. A DXA scan is extremely useful, but it is only one part of fracture-risk assessment.
The first fracture is a warning, not the end of the story
A prior fragility fracture is one of the strongest predictors of another fracture. The risk is especially important during the first several years after the initial injury. Expert groups therefore recommend that fracture care include evaluation of the underlying bone disease and the patient’s risk of falling.
The American Society for Bone and Mineral Research secondary-fracture recommendations emphasize prompt osteoporosis evaluation and treatment after hip or vertebral fracture in older adults. A 2024 systematic review also found that organized fracture-liaison programs improve bone-density testing and treatment and reduce subsequent fragility fractures compared with usual care.
This does not mean another fracture is inevitable. It means the first fracture creates an opportunity to lower future risk.
Which fractures are most concerning for osteoporosis?
Hip fracture
A low-trauma hip fracture in an older adult is strongly associated with osteoporosis and should trigger treatment planning unless another bone disorder explains the fracture. Hip fractures can cause major loss of mobility and independence, making prevention of a second fracture especially important.
Vertebral compression fracture
A spine fracture may happen after lifting, bending, coughing, or with no memorable injury. Some patients notice sudden back pain. Others develop gradual height loss, a more rounded posture, or persistent mid-back discomfort.
A vertebral fracture can be missed because the pain may improve and the patient may never receive dedicated spine imaging. If you have lost height, developed a new stooped posture, or had unexplained back pain, ask whether vertebral imaging is appropriate.
Wrist fracture
A wrist fracture after a standing-height fall is often an early warning. It may occur years before a hip fracture. Because the wrist can heal well after casting or surgery, the underlying bone problem is easy to overlook.
Shoulder and pelvic fractures
Proximal humerus and pelvic fractures after low-energy falls are also commonly associated with reduced bone strength and should prompt a review of osteoporosis risk.
Does a fragility fracture automatically mean osteoporosis?
Sometimes it does, and sometimes additional evaluation is needed.
A hip or vertebral fragility fracture in an older adult may establish a clinical diagnosis of osteoporosis even when the DXA T-score is not below -2.5, provided another metabolic bone disease is not responsible. For wrist, shoulder, or pelvic fractures, clinicians usually combine the fracture history with DXA, age, medical conditions, medications, and a fracture-risk calculator.
The Bone Health and Osteoporosis Foundation Clinician’s Guide recommends treatment for many adults with hip or vertebral fracture and for selected patients with other fragility fractures or elevated calculated fracture risk.
What is a DXA scan?
DXA, also written DEXA, stands for dual-energy X-ray absorptiometry. It is a quick, low-radiation test that measures bone mineral density, usually at the hip and lumbar spine.
The result includes a T-score:
- -1.0 or higher: generally considered normal bone density
- Between -1.0 and -2.5: low bone mass, often called osteopenia
- -2.5 or lower: osteoporosis
These categories help guide care, but they are not the entire diagnosis. Age, prior fractures, steroid use, family history, smoking, alcohol use, body weight, fall history, and other health conditions can substantially change risk.
A tool such as FRAX may be used to estimate the 10-year probability of hip fracture and major osteoporotic fracture. FRAX can be calculated with or without femoral-neck bone density, although a clinician should interpret the result in context.
Who should have osteoporosis screening?
The 2025 U.S. Preventive Services Task Force recommendation recommends screening women age 65 and older. It also recommends screening postmenopausal women younger than 65 when clinical risk assessment shows increased fracture risk.
The evidence for universal screening in men remains less certain, but men should not be overlooked. Bone-health evaluation is particularly important for men with a low-trauma fracture, long-term steroid exposure, low testosterone, low body weight, smoking history, heavy alcohol use, or conditions that affect bone metabolism.
A fracture changes the conversation. An adult over 50 with a possible fragility fracture may need evaluation even if that person has not reached the usual screening age.
What should be checked after a fragility fracture?
A thoughtful bone-health evaluation usually includes more than ordering a DXA scan.
1. Review how the fracture happened
Was it a fall from standing height? Did the bone break during routine activity? Was there a major impact? The mechanism helps distinguish a fragility fracture from a high-energy injury.
2. Review prior fractures and height loss
A previous wrist fracture, compression fracture, rib fracture, or unexplained loss of height may reveal a pattern that was not recognized earlier.
3. Review medications
Medications that can affect bone or fall risk include:
- Long-term oral or repeated high-dose corticosteroids
- Certain seizure medications
- Some breast- and prostate-cancer treatments
- Aromatase inhibitors
- Androgen-deprivation therapy
- Excess thyroid hormone replacement
- Sedating medications that increase fall risk
- Long-term use of some medications associated with impaired nutrient absorption
Do not stop a prescribed medication on your own. The goal is to identify risks and coordinate safer alternatives when appropriate.
4. Look for secondary causes
Osteoporosis can be caused or worsened by other medical conditions. Depending on the patient, laboratory testing may include blood count, kidney and liver function, calcium, phosphorus, alkaline phosphatase, thyroid function, 25-hydroxy vitamin D, parathyroid hormone, and other targeted tests. Men may need evaluation for testosterone deficiency. Patients with concerning symptoms may need testing for celiac disease, abnormal protein disorders, or other metabolic conditions.
5. Assess falls, strength, vision, and balance
Bone treatment cannot prevent every fall. Fall prevention therefore matters as much as bone density. The evaluation may include footwear, vision, blood-pressure changes, dizziness, home hazards, muscle weakness, and medications that cause sedation.
How is osteoporosis treated after a fracture?
The right plan depends on fracture type, age, kidney function, gastrointestinal history, dental health, cardiovascular history, prior osteoporosis medication, and overall fracture risk.
Treatment commonly combines the following.
Adequate protein, calcium, and vitamin D
Bone healing requires adequate nutrition. Food is generally the preferred source of calcium, with supplements used when dietary intake is not enough. Vitamin D deficiency should be corrected, but taking large doses without testing or medical guidance is not automatically better.
Calcium and vitamin D support treatment. They are not, by themselves, adequate therapy for many patients with established osteoporosis or a major fragility fracture.
Strength, weight-bearing activity, and balance training
Appropriate exercise helps preserve muscle and bone, improves balance, and reduces falls. The program should match the fracture and stage of healing. A patient recovering from a hip or vertebral fracture needs different exercises from someone with an uncomplicated wrist fracture.
Physical or occupational therapy may be helpful for gait, assistive-device use, safe transfers, home setup, and return to activity.
Prescription medication
The Endocrine Society osteoporosis guideline recommends medication for postmenopausal women at high fracture risk, especially after a recent fracture. Options include:
Bisphosphonates
Alendronate, risedronate, and intravenous zoledronic acid are common first-line options. The choice depends on kidney function, swallowing or esophageal problems, adherence, and patient preference.
In a randomized trial of patients treated after surgical repair of a low-trauma hip fracture, yearly intravenous zoledronic acid reduced subsequent clinical fractures and was associated with improved survival. The study also did not find delayed fracture healing from treatment. Results from one trial do not determine the best medication for every patient, but they support treating bone disease rather than waiting for another fracture.
Denosumab
Denosumab is an injection given every six months. It can be effective for high-risk patients, including some who cannot use a bisphosphonate. It should not be delayed or stopped without a planned follow-on therapy because bone turnover can rebound and fracture risk can rise.
Bone-building medication
Teriparatide, abaloparatide, and romosozumab may be considered for selected patients at very high risk, such as those with multiple fractures, very low bone density, or fractures while already receiving treatment. These medications are generally followed by an antiresorptive medication to preserve the bone-density gains.
Romosozumab is not appropriate for everyone, particularly some patients with recent heart attack or stroke risk. Medication selection should be individualized.
Is it safe to begin osteoporosis medication while a fracture is healing?
For most patients, osteoporosis treatment should not be postponed indefinitely while the fracture heals. The concern that all bone medications interfere with healing is not supported by the available evidence.
Timing still matters. Kidney function, calcium and vitamin D status, dental concerns, the type of fracture, surgery, and the medication selected should be reviewed. The fracture surgeon, primary-care clinician, endocrinologist, or bone-health specialist may coordinate the start date.
Can osteoporosis be treated if my DXA only shows osteopenia?
Yes. Osteopenia means the bone density is below normal but not at the T-score threshold of -2.5. A patient with osteopenia may still have high fracture risk because of age, prior fragility fracture, steroid use, falls, or other factors.
Treatment decisions should be based on the whole patient, not a single number.
What about rare medication side effects?
Patients often hear about osteonecrosis of the jaw or atypical femur fractures and become afraid to start treatment. These complications are real but uncommon at osteoporosis-treatment doses. The risk-benefit calculation is different for a person at low fracture risk than for someone who has already sustained a hip, spine, or multiple fragility fractures.
A responsible discussion includes:
- The risk of another fracture without treatment
- Expected benefit of the proposed medication
- Kidney, dental, and gastrointestinal considerations
- Duration of treatment
- Whether a medication holiday is appropriate later
- What should happen if treatment is stopped
Fear should not replace informed decision-making. The best plan is one the patient understands and can safely continue.
Dr. Morton’s orthopedic perspective
When I evaluate a fracture in an adult over 50, I want to know both how the fracture should be treated and why the bone failed.
The warning signs that deserve a bone-health workup include:
- A fracture after a standing-height fall
- More than one fracture as an adult
- A hip or vertebral compression fracture
- Loss of height or a new stooped posture
- Long-term steroid use
- Very low body weight
- Early menopause or low testosterone
- A parent with a hip fracture
- Smoking or heavy alcohol use
- Recurrent falls or worsening balance
Fixing the wrist, hip, shoulder, or other broken bone may restore function. Identifying osteoporosis may help protect the rest of the skeleton.
When should you seek urgent care?
Seek urgent medical evaluation after a fall if you have:
- Inability to stand or bear weight
- A shortened or rotated leg
- Obvious deformity
- Severe hip, groin, wrist, shoulder, or back pain
- New weakness, numbness, or loss of bowel or bladder control
- Head injury, confusion, fainting, or blood-thinner use
- An open wound near a suspected fracture
Once the immediate injury is stabilized, ask whether the fracture pattern should trigger an osteoporosis evaluation.
What should I ask at my follow-up visit?
Bring these questions:
- Was this a fragility fracture?
- Do I need a DXA scan?
- Should I have spine imaging because of height loss or back pain?
- Do I need laboratory testing for secondary causes?
- What is my risk of another fracture?
- Would osteoporosis medication help me?
- How much calcium, vitamin D, and protein do I need?
- What exercise is safe while this fracture heals?
- How can I reduce my fall risk?
- Who will follow my bone-health plan over time?
Bone-health care in Hawai‘i
Pacific Bone & Joint provides fracture evaluation and bone-health and osteoporosis care for patients across Oahu and the Big Island. Our goal is to treat the injury in front of us while also reducing the chance that another preventable fracture follows.
We see patients through our Honolulu, Waipahu, Hilo, and Kona locations. To request an evaluation, call (808) 439-6201 or contact the practice through the secure appointment request system.
This article is educational and does not replace an individualized medical evaluation. Medication choice, testing, and fracture treatment should be based on your health history and examination.
Sources and further reading
- LeBoff MS, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis International. 2022.
- U.S. Preventive Services Task Force. Osteoporosis to Prevent Fractures: Screening. 2025.
- Conley RB, et al. Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition. Journal of Bone and Mineral Research. 2020.
- Endocrine Society. Pharmacological Management of Osteoporosis in Postmenopausal Women.
- Lyles KW, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. New England Journal of Medicine. 2007.
- Danazumi MS, et al. Effectiveness of fracture liaison service in reducing the risk of secondary fragility fractures in adults aged 50 and older. Osteoporosis International. 2024.
