In short
A bone broken in a fall from standing height, in an adult over fifty, usually means the bone was weak. The fracture gets treated well in India; the osteoporosis behind it very often goes unassessed, and the next fracture arrives years later as a surprise it should not have been.
A woman of sixty-two slips in the bathroom, puts a hand out, and breaks her wrist. The orthopaedic care is excellent: the fracture is reduced, a cast or a plate, physiotherapy, a good result.
Six weeks later the cast comes off and the episode is considered closed. Nobody has asked why a wrist broke in a fall from standing height, and nobody has treated the answer.
That gap is the single largest missed opportunity in bone health.
What counts as a fragility fracture
A fragility fracture is one that occurs from a force that would not normally break a bone — most usefully defined as a fall from standing height or less, in someone aged fifty or over.
The common sites are the wrist, the hip, the upper arm, the pelvis and the spine. A fracture from a road accident or a fall down a flight of stairs is a different matter.
Spinal fractures deserve a special mention because most are never diagnosed. They often occur with no fall at all — bending to lift something, or a sudden movement — and may cause only a few weeks of back pain, or none. The signs are loss of height, a stoop that is increasing, and new back pain in someone with risk factors. A large proportion of vertebral fractures are found incidentally on a chest X-ray done for something else.
Why this matters so much
One fragility fracture substantially raises the risk of the next one, and the risk is highest in the first couple of years afterwards. That window is exactly when something can be done.
Hip fractures are the ones that change lives: loss of independence is common afterwards, and mortality in the year following a hip fracture is considerable. Preventing the second fracture is far more achievable than recovering from it.
What should happen after the fracture
A reasonable sequence, in the months after the bone has been fixed:
1. A DEXA scan. Measures bone density at the hip and spine and gives a T-score. What a DEXA scan shows explains the numbers. Important: a normal DEXA does not cancel a fragility fracture. If a bone broke from a standing fall, the bone was weak, whatever the score says — treatment is often appropriate regardless.
2. Blood tests to look for a treatable cause. Secondary osteoporosis is common and frequently missed:
- Calcium, phosphate, alkaline phosphatase, kidney and liver function
- Vitamin D, which must be corrected before certain treatments are started
- Thyroid function — an overactive thyroid causes bone loss
- Parathyroid hormone, for hyperparathyroidism
- Coeliac screening, where there is any suggestion of malabsorption
- In men, testosterone, since male osteoporosis is under-investigated
- Myeloma screening where the picture suggests it
3. A review of medicines and risks. Long-term steroids are a leading cause. So are some anti-epileptics, long-term proton pump inhibitors, certain breast and prostate cancer treatments. Smoking, more than two units of alcohol a day, low body weight and a parental hip fracture all count.
4. A fracture risk assessment — a tool such as FRAX combines age, sex, weight, previous fracture, steroid use, smoking and other factors to estimate risk over ten years, with or without a DEXA result.
5. A decision about treatment, which for most people after a fragility fracture is yes.
The treatment, in outline
Calcium and vitamin D are the foundation but not the treatment. Supplements alone do not prevent fractures in someone who has already had one. How to handle them sensibly covers the detail, including not overdoing it.
Bisphosphonates are the usual first-line drug treatment — weekly oral alendronate, or a yearly intravenous infusion of zoledronic acid where tablets are difficult. Oral bisphosphonates must be taken on an empty stomach with a full glass of water, sitting or standing upright for thirty minutes afterwards. That instruction is not fussiness; ignoring it causes oesophageal irritation and is why many people stop.
Denosumab is a six-monthly injection, used where bisphosphonates are unsuitable. One thing about it must be understood before starting: it cannot simply be stopped. Discontinuing without moving to another treatment causes a rapid loss of bone density and a risk of multiple vertebral fractures. If you are on it, do not let a dose lapse without a plan.
Anabolic treatments such as teriparatide build bone rather than preserving it, and are used in severe osteoporosis, particularly with several vertebral fractures.
Two side effects are widely discussed and worth putting in proportion: osteonecrosis of the jaw and atypical femoral fracture are both rare at the doses used for osteoporosis, and for someone who has already fractured, the risk of another fracture without treatment is far greater. Dental work is best completed before starting, and good dental hygiene maintained.
The part that is not medicine
Preventing the fall matters as much as strengthening the bone.
- Balance and strength training. Tai chi, standing on one leg while brushing teeth, sit-to-stands. The evidence for balance work in reducing falls is good.
- Eyesight and cataracts checked.
- Review of sedating medicines — sleeping tablets, some antidepressants, blood pressure medicines causing dizziness on standing.
- The bathroom, which is where a large share of these falls happen. Non-slip mats, a grab rail, and not rushing on a wet floor.
- Footwear indoors. Loose chappals on smooth floors are a genuine hazard.
- Protein and adequate calcium in the diet — milk, curd, paneer, ragi, sesame, almonds.
Why the gap exists, and how to close it
The reason so many people fall through is structural rather than anybody's fault. The surgeon fixes the bone and discharges the fracture; the physician treats the blood pressure; the bone disease belongs to nobody in particular.
Hospitals that close this gap do so with a fracture liaison service — somebody whose job is to find every patient over fifty with a fragility fracture and ensure assessment happens. Where no such service exists, the responsibility falls to the patient or the family, which is why knowing to ask matters.
A practical approach: at the fracture follow-up, ask the orthopaedic team directly whether bone assessment has been arranged and, if not, who should do it. Take the question to a physician, rheumatologist or endocrinologist rather than assuming it will happen.
What to ask for
If you or a parent has had a fracture from a minor fall and none of the above has happened, these are the questions:
- "Should I have a DEXA scan?"
- "Have the causes of weak bones been tested for — vitamin D, thyroid, parathyroid, kidney function?"
- "Do I need treatment to prevent the next fracture, not just calcium?"
- "Which of my current medicines affect my bones?"
It is never too late to ask. Someone who fractured a wrist three years ago and has had no assessment still benefits from having one now. Osteoporosis is treatable, and the treatment works best before the next fracture rather than after it.
If that assessment has not happened, you can request a callback or book a consultation.
Common questions
What is a fragility fracture?
A bone broken by a force that would not normally break it — in practice, a fall from standing height or less, in someone aged fifty or over. The wrist, hip, upper arm, pelvis and spine are the usual sites. It is taken as evidence that the bone is weak.
Do I need a DEXA scan if I have already broken a bone?
Usually yes, to measure how low the density is and to track treatment. But a normal DEXA does not cancel out the fracture. If a bone broke in a fall from standing height, treatment is often appropriate whatever the T-score shows.
Is calcium and vitamin D enough after a fracture?
No. They are the foundation on which treatment is built, not the treatment itself. Supplements alone do not prevent further fractures in someone who has already had one. Specific bone treatment, usually a bisphosphonate, is what reduces the risk of the next fracture.
How long do osteoporosis medicines need to be taken?
Typically three to five years for oral bisphosphonates, after which the need is reviewed and some people take a break. Denosumab is different and must not simply be stopped — discontinuing it without switching to another treatment causes rapid bone loss and a risk of spinal fractures.
Can a spine fracture happen without a fall?
Yes, and most are never diagnosed. They can occur while bending or lifting, and may cause only a few weeks of back pain or none at all. Losing height, an increasing stoop, or new back pain in someone with risk factors are the signs worth acting on.
Are osteoporosis drugs dangerous for the jaw?
Osteonecrosis of the jaw is rare at the doses used for osteoporosis, and much commoner at the far higher doses used in cancer care. For someone who has already had a fragility fracture, the risk of another fracture without treatment is considerably greater. Completing dental work before starting and keeping good dental hygiene is sensible.
Sources
- NHS — osteoporosis www.nhs.uk
- NIAMS — osteoporosis: diagnosis and treatment www.niams.nih.gov
- International Osteoporosis Foundation — fragility fractures www.osteoporosis.foundation
- MedlinePlus — bone density scan medlineplus.gov
This article is general information and does not replace a consultation.