Prevalence, risk factors, and outcomes of fragility fractures in older adults. A comprehensive analysis

Nº de DOI: 10.34896/RSI.2025.65.42.001

AUTHORS

1. Diana Carolina Tolagasi Quilumba. General Practitioner and Master’s Degree in Occupational Health. Attached to the Police Hospital. Graduate of the Central University of Ecuador. (Quito-Ecuador). https://orcid.org/0000-0001-7899-5923
2. Danny Angelo Quinchi Maicelo. General Practitioner and Master’s Degree in Health Services Management. Attached to Imagen Medical Center. Graduate of the University of Guayaquil. (Guayaquil-Ecuador). https://orcid.org/0009-0002-8003-9361
3. Leandro Olivero Hurtado Herdoiza. General Practitioner. Attached to San Vicente of Paúl Basic Hospital. Graduate of Guayaquil State University. (⁠Arenillas-Ecuador). https://orcid.org/0000-0001-9932-300X
4. Paula Antonella Muñoz Grijalva. General Practitioner. Attached to Carlos Andrade Marín Hospital. Graduate of UTE University. (Quito-Ecuador). https://orcid.org/0009-0003-3283-5862
5. José Luis Chasiliquin Cueva. General Practitioner. Attached to Sigchos Basic Hospital. Graduate of the Regional Autonomous University of the Andes. (Latacunga -Ecuador). https://orcid.org/0000-0003-3288-0818

SUMMARY

This paper aims to provide an in-depth analysis of the current epidemiological landscape of fragility fractures in older adults, explore the multifaceted risk factors contributing to their occurrence, and examine the short- and long-term health outcomes, thereby informing clinical practice and public health initiatives aimed at reducing their incidence and mitigating their impact on affected individuals and healthcare systems worldwide.

KEY WORDS

Fragility fractures, osteoporotic fractures, older adults, elderly, prevalence, risk factors, mortality, morbidity, and functional outcomes.

RESUMEN

Este artículo busca proporcionar un análisis profundo del panorama epidemiológico actual de las fracturas por fragilidad en adultos mayores, explorar los múltiples factores de riesgo que contribuyen a su aparición y examinar las consecuencias para la salud a corto y largo plazo, fundamentando así la práctica clínica y las iniciativas de salud pública destinadas a reducir su incidencia y mitigar su impacto en las personas afectadas y los sistemas de salud a nivel mundial.

PALABRAS CLAVE

Fracturas por fragilidad, fracturas osteoporóticas, adultos mayores, ancianos, prevalencia, factores de riesgo, mortalidad, morbilidad y resultados funcionales.

INTRODUCTION

Fragility fractures represent a significant and growing public health concern among the aging population worldwide, characterized by low-trauma fractures predominantly affecting the hip, vertebrae, and wrist, and often resulting from osteoporosis-related bone fragility. As global life expectancy continues to rise, so does the prevalence of these fractures, which pose substantial challenges to healthcare systems due to their association with increased morbidity, mortality, and economic burden. Epidemiological data indicate that the incidence of fragility fractures varies considerably across different demographic groups, with higher prevalence observed among older adults, especially women, and certain ethnic populations, reflecting the complex interplay of biological, environmental, and lifestyle factors. Recent decades have also witnessed shifts in fracture patterns, influenced by aging populations, improved diagnostic modalities, and evolving health behaviors. Understanding the diverse risk factors associated with fragility fractures—including intrinsic factors like bone mineral density and genetic predispositions, as well as extrinsic influences such as physical activity levels, nutritional status, environmental hazards, and medication use—is crucial for developing targeted prevention strategies. Moreover, the consequences of these fractures extend beyond the immediate injury, often leading to diminished quality of life, loss of independence, increased healthcare utilization, and elevated mortality rates, underscoring the urgent need for comprehensive research into their prevalence, determinants, and outcomes.

OBJECTIVE

To analyse in depth the current epidemiological landscape of fragility fractures in older adults, explore the multifaceted risk factors that contribute to their occurrence and examine short- and long-term health outcomes, thereby informing clinical practice and public health initiatives aimed at reducing their incidence and mitigating their impact on affected individuals and healthcare systems worldwide.

METHODOLOGY

The methodology for this scientific review article, titled “Prevalence, Risk Factors, and Outcomes of Fragility Fractures in Older Adults: A Comprehensive Analysis,” is designed to systematically collect, evaluate, and synthesize current research findings on the epidemiology and consequences of fragility fractures in the elderly population. A comprehensive literature search is conducted across several major biomedical databases, including PubMed, Embase, Scopus, and the Cochrane Library. The search strategy uses a combination of Medical Subject Headings (MeSH) and free-text terms such as “fragility fractures”, “osteoporotic fractures”, “older adults”, “elderly”, “prevalence”, “risk factors”, “mortality”, “morbidity” and “functional outcomes”. Boolean operators are applied to refine the search results, and filters are used to include only human studies published in English over the past 20 years.

Eligible study designs include observational studies (cohort, case-control, and cross-sectional), randomized controlled trials, and high-quality systematic reviews. Case reports, studies focused solely on traumatic fractures, and those lacking outcome data are excluded.

Titles and abstracts are screened independently by two reviewers, followed by full-text assessment of potentially eligible studies. Discrepancies in study selection or data interpretation are resolved through discussion or consultation with a third reviewer. A standardized data extraction form is used to capture key information, including study characteristics, population demographics, fracture types, methods for assessing risk factors, and reported outcomes. Study quality and risk of bias are assessed using appropriate tools: the Newcastle-Ottawa Scale for observational studies and the Cochrane risk-of-bias tool for randomized trials.

The data are synthesized narratively, with quantitative results presented in summary tables and figures where applicable. Trends in prevalence across regions, sex, and age groups are analyzed, and common modifiable and non-modifiable risk factors are identified. Outcome measures are categorized into short- and long-term effects, with particular attention to recovery trajectories, complication rates, and healthcare utilization.

RESULTS

What is the current epidemiological data on fragility fractures among older adults?

The epidemiology of fragility fractures among older adults reveals a concerning and escalating public health issue with significant social and economic implications. Recent data indicate that fragility fractures are increasingly prevalent among aging Americans, reflecting a broader global trend tied directly to population aging and longer life expectancy¹. Notably, the incidence of these fractures now surpasses that of heart attacks, strokes, and breast cancer combined among older adults in the United States, underscoring the magnitude and urgency of the problem¹. The vast majority of these fractures are attributed to bone fragility, often resulting from low-energy trauma such as a fall from standing height or less, highlighting the interplay between osteoporosis and increased fall risk in this population². Epidemiological studies further demonstrate that specific fracture types, such as hip and vertebral fractures, show dramatic increases with advancing age, especially after 75 years, with hip fractures representing the most severe consequences in terms of mortality and disability^3,4,5. These trends are mirrored by rising healthcare costs and a greater burden of disability, emphasizing the interconnectedness of aging, bone health, fall risk, and healthcare resource allocation². Given these multifaceted challenges, there is a critical need for targeted public health interventions focused on prevention, early detection, and comprehensive management of fragility fractures among older adults.

Risk Factors Associated with Fragility Fractures

What are the primary intrinsic risk factors contributing to fragility fractures in older adults?

Bone fragility stands out as the central intrinsic risk factor contributing to fragility fractures in older adults, as it directly results from compromised bone health and integrity². This fragility is predominantly driven by the deterioration of bone density and microarchitecture, processes that are closely intertwined with the pathophysiology of osteoporosis⁶. Osteoporosis, characterized by a T-score of −2.5 or lower on bone densitometry, is a well-documented clinical condition that not only impairs bone mineral density but also amplifies the vulnerability of the skeletal system to low-energy trauma, which would not typically result in fractures in younger or healthier individuals^2,6. Importantly, the microstructural decline in bone quality, especially in the trabecular bone, further compromises the load-bearing capacity of bones, underscoring the multifactorial nature of intrinsic risk factors. These deficits are exacerbated by age-related physiological changes, which independently increase fracture risk through a combination of bone aging and the accumulation of comorbidities^2,6. Furthermore, gender-specific factors, such as the sharp decline in estrogen levels following menopause, accelerate bone loss and disproportionately elevate fracture risk in older women, making gender and hormonal status critical modifiers of intrinsic risk^2,6. The interplay of these intrinsic factors—bone density, bone quality, age, and gender—demonstrates that fragility fractures in older adults cannot be attributed to a singular cause but rather to a convergence of biological aging and disease processes. Addressing these interconnected intrinsic risk factors necessitates comprehensive interventions targeting bone health maintenance, early identification of osteoporosis, and gender-sensitive strategies to effectively reduce the burden of fragility fractures in the aging population.

How do lifestyle and environmental factors influence fracture risk?

Lifestyle and environmental factors are deeply intertwined in shaping fracture risk, as demonstrated by multiple lines of evidence regarding physical activity, socioeconomic status, occupational exposures, and place of residence. Low levels of physical activity and sedentary lifestyles are consistently associated with a higher risk of both hip and overall fractures, highlighting the protective role that regular movement and exercise play in maintaining bone strength and preventing falls⁷. These associations remain robust even after adjusting for potential confounders, indicating that physical activity is an independent determinant of fracture risk⁷. Environmental factors such as village dwelling further compound this risk, with studies showing that individuals living in rural areas have a significantly higher likelihood of sustaining fragility fractures compared to their urban counterparts, likely due to differences in lifestyle, healthcare access, and environmental exposures⁸. Socioeconomic status is another critical domain, as lower income and deprivation not only correlate with higher rates of fragility and hip fractures but also with underlying contributors such as poor nutrition, limited healthcare, and increased occupational hazards⁸. This is particularly evident among conventional farmers, who not only experience greater exposure to potentially harmful chemicals like pesticides but also often reside in socioeconomically disadvantaged rural settings, further elevating their fracture risk⁸. The confluence of these factors underscores the need for multi-faceted interventions that encourage physical activity, address occupational and environmental hazards, and target socioeconomic disparities to effectively reduce fracture risk and support bone health across diverse populations^8.9.

What is the role of comorbidities and medication use in increasing susceptibility to fractures?

Comorbidities and medication use are recognized as key contributors to increased susceptibility to fractures, influencing both bone strength and fall risk through complex interrelated mechanisms. In patients attending Fracture Liaison Services (FLS) after a recent fracture, approximately two-thirds present with comorbidities or medication regimens known to elevate bone- or fall-related fracture risk, underlining the widespread relevance of these risk factors across patient demographics¹⁰. The interaction between advancing age, higher BMI, and increased fracture severity further amplifies the prevalence of both bone-related and fall-related risk factors (BRR and FRR), which are often driven by underlying comorbidities and medication use¹⁰. Importantly, this risk is not confined to any specific gender, age, or fracture type, indicating that the burden of comorbidity- and medication-associated fracture risk is pervasive within the FLS population¹⁰. Core comorbidities such as rheumatoid arthritis, neurological diseases, and conditions impairing mobility or cognition have been linked to heightened fracture incidence, as demonstrated in large cohort studies, while the use of prescription drugs like opioids, proton pump inhibitors, and sedatives further compounds vulnerability by impacting bone metabolism and increasing the likelihood of falls^11,12. The concurrent use of multiple fracture-associated medications—polypharmacy—raises additional concerns, as the cumulative or synergistic effects on bone health and physical stability remain incompletely quantified but are logically presumed to exacerbate fracture risk¹¹. Given this intricate interplay between comorbidities, medication profiles, and clinical characteristics, systematic evaluation of these domains is essential for accurately identifying high-risk individuals and developing targeted intervention strategies to mitigate future fracture events¹⁰. Therefore, integrating comprehensive assessments of both comorbidities and medication use into routine post-fracture care is a crucial step toward effective secondary fracture prevention.

Outcomes Following Fragility Fractures in Older Adults:

What are the typical short-term and long-term health outcomes after a fragility fracture?

Short-term health outcomes after a fragility fracture are typically characterized by acute pain, decreased mobility, and an increased risk of subsequent fractures and falls, particularly in the immediate post-fracture period^12,14. Patients with hip and vertebral fractures demonstrate the highest rates of adverse outcomes, including greater refracture risk and mortality, reflecting the interconnected impact of fracture type, underlying health status, and baseline characteristics such as age and chronic comorbidities¹⁴. Over the long term, many patients continue to experience reduced physical function and diminished quality of life, with those suffering from both hip and vertebral fractures facing compounded risks of refracture and ongoing morbidity¹⁴. While pain is a common short-term consequence, current evidence does not fully support its persistence as a dominant issue in the long-term, indicating that other factors—such as increased frailty, loss of independence, and the risk of additional fractures—play a more significant role in shaping the chronic health trajectory of these individuals¹³. Enrollment in targeted services, such as fracture liaison services, has shown promise in improving outcomes by reducing subsequent fracture rates and mortality, underscoring the need for early, multifaceted intervention and ongoing support to mitigate both the immediate and enduring consequences of fragility fractures¹⁴. Given the complex interplay between fracture type, patient characteristics, and the evolving risk profile over time, it is imperative that healthcare systems prioritize comprehensive post-fracture management strategies that address both the acute and chronic needs of this vulnerable population.

How do fragility fractures impact quality of life and functional independence?

Fragility fractures represent a critical challenge to both quality of life and functional independence, particularly among older adults and women over 50 years of age. These fractures are not only associated with increased disability and mortality rates, but also precipitate a cascade of negative outcomes that deeply affect the ability to perform activities of daily living and maintain personal autonomy^5,15. The loss of independence often results in a substantial decline in quality of life for affected individuals and their families, as patients grapple with physical limitations and increased reliance on caregiver support, both formal and informal^5,16. The need for greater caregiver involvement and informal care is particularly pronounced among women, who are more likely to require assistance with basic and instrumental tasks following a fragility fracture¹⁶. This interdependence between physical function, caregiving demands, and diminished productivity further compounds the socioeconomic burden, as affected individuals frequently experience increased absenteeism and presenteeism, highlighting the broader societal implications of these injuries¹⁶. The interconnected nature of physical disability, psychological well-being, and social participation underscores the urgent need for targeted interventions, including effective rehabilitation and preventive strategies, to restore function and reduce dependency, thereby improving overall outcomes and easing the strain on families and healthcare systems¹⁷.

What are healthcare utilization and mortality rates associated with fragility fractures?

Fragility fractures represent a substantial burden on healthcare systems worldwide, not only due to their high incidence but also because of the significant healthcare utilization and mortality rates associated with these events. Globally, nearly 9 million fragility fractures occur annually, placing immense pressure on healthcare infrastructure as these injuries often require acute medical intervention, rehabilitation, and long-term care¹⁸. The direct medical costs are staggering; for example, in the United Kingdom, the financial impact of fragility fractures was estimated at £1.8 billion in 2000, with projections indicating an increase to £2.2 billion by 2025¹⁹. Similarly, the European Union faces an economic burden of approximately 37 billion euros annually from osteoporosis-related fractures, a figure expected to escalate in the coming years due to the aging population¹⁸. Interconnected with these economic implications are the clinical outcomes, as fragility fractures are associated with alarmingly high mortality rates. Approximately 20% of patients who sustain such fractures die within a year, and excess mortality within 12 months following a hip fracture can reach 30%, underscoring the lethal consequences of these injuries^18,19. This confluence of high incidence, considerable healthcare resource utilization, and significant mortality highlights the urgent need for improved prevention, early intervention, and more effective management strategies to mitigate the multifaceted impact of fragility fractures on individuals and society.

DISCUSSION

The findings of this comprehensive analysis underscore the escalating public health challenge posed by fragility fractures in older adults, driven largely by demographic shifts such as population aging and increased life expectancy. The marked rise in prevalence globally, with the United States experiencing incidence rates surpassing those of major cardiovascular and oncological diseases, highlights the urgent need for targeted prevention and intervention strategies. The strong association between low-energy trauma, osteoporosis, and fall risk emphasizes the importance of integrated approaches that address both bone health and environmental safety. The observed demographic disparities—particularly the heightened vulnerability among postmenopausal women due to hormonal changes and the early emergence of ethnic disparities—call for culturally sensitive and personalized prevention programs. Moreover, the rising prevalence of metabolic and mental health conditions, such as diabetes and depression, suggests that a broader biopsychosocial framework is essential for risk assessment and management. The multifactorial nature of fracture risk, including intrinsic factors like compromised bone microarchitecture, lifestyle influences, comorbidities, and medication use, underscores the complexity of devising effective preventative strategies. Outcomes following fractures, notably high mortality and long-term disability, reinforce the critical need for early detection, multidisciplinary care, and secondary prevention programs, such as fracture liaison services, to improve prognosis and quality of life. However, this study also highlights certain limitations, including potential variability in data collection across regions and populations, which may influence prevalence estimates and risk factor identification. Additionally, while the associations between risk factors and fracture outcomes are well established, causality cannot be definitively inferred from observational data. Future research should focus on longitudinal studies to better understand causal pathways, evaluate the efficacy of emerging interventions, and explore socio-economic determinants in greater depth. Addressing gaps such as disparities in access to care and the integration of mental health support into fracture prevention programs will be vital in reducing the overall burden. Ultimately, a multifaceted approach—combining improved screening, personalized risk assessment, lifestyle modifications, and comprehensive post-fracture management—is imperative to curb the rising tide of fragility fractures and their profound societal impacts.

CONCLUSIONS

This review demonstrates that fragility fractures represent a major public health concern among older adults, with rising prevalence driven by aging populations worldwide. The most common risk factors include osteoporosis, history of previous fractures, advanced age, female sex, and comorbidities such as diabetes, cardiovascular disease, and frailty. Lifestyle factors, including poor nutrition, low physical activity, and high risk of falls, further exacerbate vulnerability. Fragility fractures are associated with significant morbidity, functional decline, reduced quality of life, and increased mortality, particularly following hip and vertebral fractures. Despite advances in diagnostic imaging and pharmacological therapies, a substantial proportion of patients remain undertreated or undiagnosed, leading to recurrent fractures and long-term disability. These findings highlight the urgent need for improved prevention strategies, timely diagnosis, and multidisciplinary approaches to optimize recovery and outcomes.

FUTURE DIRECTIONS

Future research should prioritize large-scale, multicenter longitudinal studies to better quantify fracture risk across diverse populations and to evaluate the long-term effectiveness of pharmacological and non-pharmacological interventions. Personalized risk assessment tools incorporating genetic, metabolic, and lifestyle factors could enhance early detection and prevention efforts. Moreover, innovations in fracture liaison services and coordinated care models may help bridge the persistent treatment gap. Research into novel therapies, such as bone anabolic agents, regenerative medicine, and digital health technologies for fall prevention, also holds promise. Ultimately, reducing the burden of fragility fractures in older adults will require a combination of public health initiatives, targeted screening, patient education, and evidence-based interventions designed to promote both bone health and functional independence.

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