Prevalence, risk factors, and outcomes of fragility fractures in the elderly population

Nº de DOI: 10.34896/RSI.2026.14.24.001

AUTHORS

1. Alan Leonel Quiñónez Plaza. General Practitioner. Attached to Private Clinics in Ecuador. Graduate of the State University of Guayaquil. (Guayaquil-Ecuador). https://orcid.org/0009-0001-2028-7438
2. Brenda Paulina Sotalín Sotalín. General Practitioner. Attached to Private Clinics of Ecuador. Graduated from the Pontifical Catholic University of Ecuador. (Quito-Ecuador). https://orcid.org/0009-0009-5637-5059
3. Edwin Vinicio Pogo Arteaga. General Practitioner. Attached to the IESS General Hospital in Ibarra. Graduate of the Central University of Ecuador. (Ibarra-Ecuador). https://orcid.org/0009-0008-9366-5728
4. Nazario Vladimir Fiallos Peña. General Practitioner. Attached to San Vicente de Paul General Hospital. Graduate of the Central University of Ecuador. (Ibarra-Ecuador). https://orcid.org/0009-0006-2924-5636
5. Josselyn Rocio Pilco Bravo. General Practitioner and Master’s Degree in Criminalistics and Forensic Sciences. Attached to SOLCA Chimborazo Oncology Unit. Graduate of the National University of Chimborazo. (Riobamba-Ecuador). https://orcid.org/0009-0007-6857-5643

SUMMARY

This paper aims to synthesize existing knowledge on the prevalence, risk factors, and consequences of fragility fractures in the elderly, critically evaluate current diagnostic and therapeutic strategies, and propose future directions to better prevent and manage these debilitating injuries in an increasingly aging world.

KEY WORDS

Fragility fractures, osteoporosis, older adults, falls, population ageing, quality of life, functional decline, rehabilitation, fracture prevention.

RESUMEN

Este artículo tiene como objetivo sintetizar el conocimiento existente sobre la prevalencia, los factores de riesgo y las consecuencias de las fracturas por fragilidad en personas mayores, evaluar críticamente las estrategias diagnósticas y terapéuticas actuales y proponer futuras estrategias para una mejor prevención y gestión de estas lesiones debilitantes en un mundo cada vez más envejecido.

PALABRAS CLAVE

Fracturas por fragilidad, osteoporosis, adultos mayores, caídas, envejecimiento poblacional, calidad de vida, deterioro funcional, rehabilitación, prevención de fracturas.

INTRODUCTION

As populations in Western countries continue to age rapidly, the prevalence of fragility fractures among the elderly has emerged as a significant public health concern, with profound implications for individuals and healthcare systems alike. Fragility fractures typically resulting from low-energy trauma such as falls—are increasingly common in this demographic, profoundly impacting their quality of life by diminishing autonomy, increasing disability, and contributing to elevated mortality rates. The socioeconomic burden associated with these injuries is substantial, encompassing increased healthcare costs, long-term care needs, and diminished productivity, thereby stressing already strained healthcare resources in aging societies. Despite the growing recognition of their importance, identifying at-risk individuals remains challenging due to intrinsic factors like osteoporosis, comorbidities, and extrinsic elements such as environmental hazards, compounded by limitations in current diagnostic tools that hinder early detection and preventive interventions. Consequently, managing fragility fractures effectively demands a comprehensive understanding of their risk factors, preventive strategies, and treatment options areas that are continually evolving as new evidence emerges. Current management practices, while advancing, still face notable limitations, underscoring the urgent need for innovative approaches to improve outcomes.

OBJECTIVE

To synthesize current knowledge on the prevalence, risk factors, and consequences of fragility fractures in older adults, critically evaluate current diagnostic and therapeutic strategies, and propose future directions for better preventing and treating these debilitating injuries in an increasingly aging world.

METHODOLOGY

This study employed a narrative review methodology to synthesize current evidence on fragility fractures in older adults across Western populations. A comprehensive search was conducted in PubMed, Scopus, and Google Scholar, complemented by clinical practice guidelines and reports from international organizations focused on osteoporosis, falls, and geriatric fracture care. The search prioritized articles published between 2000 and 2024 in English and Spanish, using terms such as “fragility fractures,” “osteoporotic fractures,” “hip fracture,” “older adults,” “falls,” and “functional outcomes.” Studies were included if they examined prevalence trends, intrinsic and extrinsic risk factors, diagnostic challenges, or management strategies relevant to elderly populations. Exclusion criteria encompassed high-energy trauma fractures, studies not specific to older adults, and papers lacking methodological clarity or clinically meaningful outcomes. Given the heterogeneity of study designs, no meta-analysis was performed; instead, findings were organized thematically and described narratively to provide an integrated and critical interpretation of the available evidence.

RESULTS

Prevalence and Socioeconomic Impact of Fragility Fractures in the Elderly:

What is the current prevalence of fragility fractures among elderly populations in Western countries?

The current prevalence of fragility fractures among elderly populations in Western countries is notably high, with a distinct gender disparity in incidence rates. Women represent a disproportionately affected group, accounting for 71 percent of osteoporosis-related fractures, while men constitute the remaining 29 percent, underscoring the need to address sex-specific risk factors and prevention strategies¹. This widespread occurrence is further highlighted by data from the United States, where over 2 million osteoporosis-related fractures are reported annually, a figure that signals an urgent public health issue among the aging demographic¹. The increasing prevalence is closely linked to demographic shifts; as the population continues to age and the proportion of elderly individuals rises, the absolute number of fragility fractures is expected to escalate, placing additional pressure on healthcare systems and necessitating proactive interventions targeting at-risk populations¹. Given these interconnected trends, rising age, growing fracture incidence, and gender differences, comprehensive, multidisciplinary approaches are imperative to mitigate the personal and societal burden of fragility fractures among the elderly.

How do fragility fractures affect the quality of life and autonomy in elderly individuals?

Fragility fractures profoundly disrupt both the quality of life and the autonomy of elderly individuals by initiating a cascade of physical and functional limitations that often persist long after the initial injury. The immediate aftermath of such fractures is typically characterized by substantial pain, immobility, and a loss of confidence in performing daily tasks, all of which combine to reduce health-related quality of life and increase dependency². As a result, elderly patients frequently experience a marked decline in their ability to live independently, with only about 40% able to regain their previous levels of autonomy and functional capacity³. The interconnection between diminished mobility, increased frailty, and the onset of other chronic conditions is pivotal: fractures not only serve as indicators of underlying osteoporosis but also exacerbate pre-existing frailty, further impeding recovery and compounding the risk of subsequent injuries⁴. This cycle of declining independence and quality of life is often intensified by secondary complications such as cognitive impairment, chronic pain, and the challenges of post-fracture rehabilitation, which together amplify the vulnerability of this population^3,4. Given these multifaceted impacts, it is imperative to prioritize comprehensive fracture prevention and management strategies addressing both the immediate effects of fractures and the underlying causes like osteoporosis to help preserve autonomy, support recovery, and enhance the long-term well-being of elderly individuals^2,4.

What are the socioeconomic consequences of rising fragility fracture rates in ageing societies?

The socioeconomic consequences of rising fragility fracture rates extend beyond individual health and autonomy, profoundly impacting entire communities and healthcare systems, especially within aging societies. Notably, these consequences are amplified in deprived populations, where increased fracture rates both reflect and reinforce existing socioeconomic disparities; such inequalities are evident as individuals in low-income areas or those living in poverty experience significantly higher incidences of hip fractures and other osteoporotic injuries, compared to their more affluent counterparts⁵. This association is not limited to hip fractures alone: deprivation also correlates strongly with elevated risks of wrist and vertebral fractures, particularly among men, signaling a multifaceted public health challenge that cuts across gender lines and fracture types⁵. The cumulative effect of these disparities manifests in a greater burden of disability, increased healthcare utilization, and higher costs for both families and public health systems, ultimately widening health inequalities and perpetuating cycles of disadvantage⁵. To address these interconnected domains health, economic security, and social equity targeted interventions are needed, focusing on both fracture prevention and the underlying socioeconomic factors that exacerbate vulnerability among aging populations.

Risk Factors and Diagnostic Challenges in Fragility Fractures:

What intrinsic and extrinsic factors increase the risk of fragility fractures in the elderly?

A complex interplay of intrinsic and extrinsic factors underlies the heightened risk of fragility fractures in the elderly, with these elements frequently compounding one another to increase overall vulnerability. Intrinsically, aging itself precipitates a cascade of physiological changes, such as decreased bone mineral density and osteoporosis, which significantly weaken the skeletal structure and render bones more susceptible to fracture even under low-energy impacts^6,7. Postmenopausal hormonal changes further exacerbate this decline in bone quality, explaining the observed gender disparity wherein women are approximately twice as likely to experience fragility fractures compared to men^6,7. Alongside bone-related factors, age-associated reductions in muscle mass and strength commonly referred to as sarcopenia contribute to impaired balance and mobility, thus increasing the likelihood of falls and subsequent fractures⁷. Extrinsically, falls represent a predominant risk factor; the elderly are particularly prone to falls due to their diminished physical capacity and frailty, and even a minor fall from standing height can precipitate serious fractures, especially in vulnerable anatomical sites such as the hip^6,8. The interconnectedness of these domains is evident: diminished bone and muscle integrity not only heighten the risk of sustaining a fracture but also amplify the consequences of extrinsic hazards like falls, leading to a vicious cycle of injury, loss of independence, and further decline^6,7,8. Therefore, a comprehensive approach that addresses both the intrinsic deterioration of musculoskeletal health and the extrinsic environmental and behavioral risks is essential for effective prevention and management of fragility fractures in the elderly⁶.

What are the current limitations of diagnostic tools for identifying at-risk individuals?

Despite advancements in diagnostic imaging, significant limitations persist in accurately identifying individuals at risk, especially among aging populations prone to fragility fractures. One of the core challenges lies in the balance between the increased clarity that imaging offers and the uncertainty it introduces; while imaging can reveal potential diseases before symptoms manifest, this early detection is often accompanied by ambiguous findings that do not always translate into clear clinical action⁹. The prevalence of incidental findings, or incidentalomas, further complicates the landscape, as these discoveries may lack clinical relevance but frequently trigger a cascade of additional tests, interventions, and patient anxiety, ultimately demonstrating the limited specificity of current diagnostic tools in distinguishing between significant and insignificant results⁹. Additionally, the ongoing trend toward defensive medicine—where clinicians order more tests out of litigation fears—exacerbates the overutilization of imaging resources, resulting in unnecessary procedures that dilute the precision of risk stratification and contribute to escalating healthcare costs without substantially improving patient outcomes⁹. Addressing these interconnected challenges requires a concerted effort to refine diagnostic protocols, enhance physician education about the nuances of predictive imaging, and implement evidence-based guidelines that prioritize meaningful risk identification over indiscriminate testing.

How can early identification and targeting of high-risk patients be improved?

Given the substantial impact of fragility fractures on the autonomy and functional abilities of older adults, the early identification and targeting of high-risk patients becomes imperative to prevent further deterioration and reduce subsequent healthcare utilization. Quantitative risk prediction models that utilize administrative data are a common mechanism for identifying patients at elevated risk for adverse outcomes such as fractures; these tools enable providers to segment patient populations and facilitate efficient allocation of preventive resources^10,11. However, while calculated risk scores are instrumental in streamlining the identification process, they are not without limitations; for instance, current quantitative approaches often fail to account for nuanced patient characteristics such as socioeconomic status, psychosocial factors, or the individual’s willingness and ability to participate in interventions which are critical in shaping both risk and response to management strategies¹¹. This limitation underscores the interconnectedness between data-driven identification methods and the broader social and behavioral domains that influence patient engagement and health outcomes. To address these gaps, integrating regular, multifaceted assessments into standard healthcare practices can enhance the early detection network, allowing for more holistic identification of those at risk and enabling timely, targeted interventions that may improve long-term prognoses for vulnerable populations¹². Therefore, there is a pressing need for healthcare systems to evolve beyond claims-based algorithms, adopting a multidimensional approach that incorporates both quantitative and qualitative data to more accurately identify and support high-risk individuals.

Management Strategies and Outcomes of Fragility Fractures:

What are the current best practices for the management and prevention of fragility fractures?

Current best practices for the management and prevention of fragility fractures are anchored in a comprehensive, multidisciplinary approach that integrates both individualized and population-level interventions. Central to these strategies is the prescription of multicomponent exercise programs, which are endorsed by clinical practice guidelines for their proven efficacy in enhancing bone health, optimizing muscle mass and strength, and improving functional mobility—all critical factors that directly reduce fracture risk¹³. These exercise interventions are most effective when tailored to the unique medical history, health status, and personal preferences of each individual, underscoring the importance of personalized care to maximize adherence and benefit¹³. In addition, falls prevention strategies and lifestyle modifications, such as weight-bearing activities and balance training, are routinely incorporated to address the multifactorial nature of fracture risk and to support older adults in maintaining independence^3,13. The integration of these evidence-based interventions into real-world healthcare settings requires ongoing efforts from policymakers, healthcare professionals, and consumers, who must collaborate to ensure high-value care and broad implementation across diverse populations¹³. Furthermore, regular risk assessments including bone density evaluations, assessment of nutritional status (calcium and vitamin D intake), and early identification of high-risk individuals are essential for guiding both preventive and therapeutic interventions¹⁴. Ultimately, the synthesis of these interconnected domains exercise, individualized care, lifestyle modification, and systematic risk assessment forms the backbone of current best practices, and continued emphasis on these actions, along with robust interprofessional collaboration, is necessary to further reduce the global burden of fragility fractures^3,13.

What are the limitations of existing clinical and therapeutic options for fragility fractures?

Despite the rising prevalence of fragility fractures among the aging population, current clinical and therapeutic approaches exhibit several notable limitations that hinder optimal patient outcomes¹⁴. Firstly, many interventions primarily focus on treating the acute fracture episode, often neglecting comprehensive long-term management strategies necessary to prevent recurrent fractures. This short-term approach can result in a cycle of repeated injury and hospitalization, particularly detrimental to elderly patients who are already at heightened risk of comorbidities¹⁴. Furthermore, the efficacy of pharmacological treatments such as bisphosphonates or anabolic agents is often compromised by issues of poor patient adherence, potential side effects, and contraindications in individuals with multiple health conditions commonly seen in older adults¹⁴. Additionally, rehabilitation and post-fracture care services are not uniformly accessible or consistently integrated into care pathways, leading to disparities in functional recovery and quality of life. These interconnected challenges underscore the need for a more holistic, multidisciplinary approach that not only addresses the acute fracture but also incorporates preventive, rehabilitative, and patient-centered strategies to mitigate the long-term burden of fragility fractures¹⁴.

What new directions are being proposed for improving outcomes in elderly patients with fragility fractures?

To counteract the substantial decline in autonomy and functional status observed after fragility fractures, emerging proposals emphasize the adoption of a multidisciplinary approach that integrates the expertise of orthopedic surgeons, geriatricians, physiotherapists, occupational therapists, dieticians, social workers, and caregivers to comprehensively address the complex health needs of elderly patients¹⁵. This collaborative model not only facilitates timely surgical intervention and medical optimization, but also enables early mobilization and coordinated rehabilitation, which are critical for reducing complications and promoting recovery¹⁵. In addition, new directions are prioritizing preventive strategies, such as fall prevention programs and proactive management of osteoporosis, which have been shown to be vital in reducing both the incidence and recurrence of fragility fractures in this vulnerable demographic¹⁵. Addressing these interconnected domains acute care, rehabilitation, and prevention can significantly improve outcomes in terms of mortality, functional independence, and quality of life, underscoring the urgent need for the widespread implementation of multidisciplinary and preventive care frameworks in the management of elderly patients with fragility fractures¹⁵.

DISCUSSION 

The findings of this comprehensive review underscore the significant public health challenge posed by fragility fractures among the elderly, particularly within Western populations where demographic shifts are expected to amplify the burden. The high prevalence rates, especially among women, highlight persistent gender disparities that warrant targeted prevention strategies. The substantial impact on quality of life, with only approximately 40% of elderly patients regaining their prior functional status, emphasizes the critical need for effective management and rehabilitation protocols. Moreover, the socioeconomic implications, notably in deprived communities, reveal how fragility fractures exacerbate existing health disparities and impose considerable economic strains on healthcare systems. While advances in diagnostic tools have improved risk stratification, limitations such as ambiguous findings and overutilization raise concerns about early identification and personalized intervention. The current management approaches, although multidisciplinary in principle, face real-world challenges including poor treatment adherence, side effects, and disparities in access to rehabilitative services, which can hinder optimal outcomes. The underutilization of pharmacological therapies like bisphosphonates further highlights gaps in treatment implementation. Emerging models advocating integrated, patient-centered care—encompassing surgical, medical, and rehabilitative strategies—offer promising avenues for improving outcomes, yet their widespread adoption remains limited by systemic barriers. Future research should focus on refining risk assessment models to incorporate social and behavioral factors, developing more tolerable and adherence-friendly treatments, and establishing standardized post-fracture care pathways. Addressing these gaps requires a coordinated effort across healthcare, social policy, and community sectors to develop sustainable, comprehensive frameworks that can adapt to the evolving demographic landscape. Recognizing the complex interplay of intrinsic and extrinsic risk factors, this study advocates for a holistic approach that not only treats fractures but also emphasizes prevention, early detection, and long-term management to mitigate the profound individual and societal impacts of fragility fractures in the aging population.

CONCLUSIONS

1. Fragility fractures in older adults constitute a major and escalating public health concern, particularly in Western countries where demographic aging continues to intensify. Their high prevalence, especially among women, reflects persistent biological and social inequities that remain insufficiently addressed in current healthcare frameworks. Beyond their frequency, these fractures have profound consequences for affected individuals, leading to substantial declines in mobility, autonomy, and overall quality of life; only a minority of older adults regain their pre-fracture functional status. These outcomes underscore the importance of early detection, preventive interventions, and comprehensive management strategies.
2. Despite significant advances in diagnostic imaging and risk assessment tools, notable limitations persist. Ambiguous or incidental findings often complicate clinical decision-making, contributing to both underdiagnosis and overtreatment. Additionally, current risk prediction models frequently fail to integrate relevant social and behavioral determinants of health, reducing their precision in identifying individuals most vulnerable to fracture. These limitations highlight the pressing need for diagnostic approaches that balance technological capabilities with individualized clinical judgment.
3. Therapeutically, fragility fractures expose critical gaps in continuity of care. Although multidisciplinary models—including orthogeriatric co-management, fracture liaison services, and structured rehabilitation—have demonstrated improvements in outcomes, their implementation remains inconsistent across healthcare systems. Medication adherence challenges, side effects, and the burden of multimorbidity further complicate long-term management. These barriers contribute to a recurrent cycle of re-fracture, functional decline, and increased healthcare utilization.
4. Overall, the evidence underscores the necessity of reframing fragility fractures not as isolated orthopedic events but as manifestations of a broader, multifactorial geriatric syndrome. Effective solutions require integrated, patient-centered approaches that combine medical treatment, functional rehabilitation, fall prevention, and social support. Strengthening interprofessional collaboration, expanding access to evidence-based interventions, and reducing systemic inequities will be essential steps toward improving outcomes and reducing the substantial societal burden associated with fragility fractures in aging populations.

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