European Journal of Cardiovascular Medicine

Fragility fractures are low-energy fractures that occur from a fall from standing height or less and reflect reduced bone strength, most commonly due to osteoporosis. They represent a major public health challenge because they lead to pain, loss of mobility, prolonged dependence, and increased mortality, particularly after hip fractures [1,2]. As populations age, the absolute number of osteoporotic fractures continues to rise, and the burden extends beyond the index injury to include recurrent fractures and long-term institutional care [2].

The anatomical distribution of fragility fractures follows a characteristic pattern. Proximal femur (hip), vertebral compression fractures, and distal radius (wrist) fractures constitute a large proportion of osteoporotic injuries and are included in widely used fracture risk prediction frameworks such as FRAX [1,3]. A sentinel fragility fracture also signals elevated risk of subsequent fractures; meta-analytic evidence shows that a prior fracture substantially increases future fracture risk [12]. Within hip fractures, intertrochanteric and femoral neck fractures predominate and are associated with different perioperative risks and functional trajectories [1]. Early medical morbidity is common after hip fracture, and excess mortality has been consistently documented in older adults following this injury [4].

Risk factors for fragility fractures are multidimensional. Low bone mineral density, increasing age, female sex, and certain comorbidities contribute to impaired bone strength and falls vulnerability [3,7]. Prolonged corticosteroid exposure accelerates bone loss and increases fracture risk, while vertebral fractures can occur silently until an acute event or incidental detection [8,13]. Equally important, falls act as the proximate trigger for many fractures, and fall-risk contributors such as impaired vision, sedative use, and home environmental hazards are potentially modifiable targets for prevention.

Despite the availability of effective anti-osteoporosis therapies, post-fracture evaluation and treatment remain inconsistent worldwide. Recent evidence continues to show a substantial osteoporosis treatment gap after fragility fractures, even in centers with established orthopaedic pathways [14]. Guideline-based care emphasizes secondary prevention after a sentinel fracture, including bone health assessment, vitamin D optimization, and initiation of pharmacotherapy when indicated [5,8].

In this context, the present study was undertaken in a tertiary-care teaching hospital to characterize the pattern of osteoporotic fragility fractures among adults aged ≥50 years and to document associated clinical risk factors, management approaches, and short-term outcomes. The objectives were: (1) to describe the distribution of fragility fractures by anatomical site and subtype; (2) to quantify common osteoporosis- and fall-related risk factors; and (3) to assess 30–90 day outcomes including complications, readmissions, mortality, and functional mobility.

Study design and setting: This hospital-based observational study was conducted in the Department of Orthopaedics, Government Medical College (GMC), Ananthapuramu, Andhra Pradesh, India, over an 8-month period from May 2023 to December 2023.

Participants: Adults aged ≥50 years presenting to the emergency department or orthopaedic outpatient/inpatient services with a recent fracture were screened consecutively. A fragility fracture was defined as a fracture sustained after low-energy trauma (fall from standing height or less) involving typical osteoporotic or insufficiency sites [1,3].

Inclusion criteria: (1) age ≥50 years; (2) radiologically confirmed fracture; and (3) low-energy mechanism consistent with fragility injury.

Exclusion criteria: Fractures resulting from high-energy trauma (road traffic accident, fall from >1 m), pathological fractures due to malignancy, periprosthetic fractures, and patients unwilling for follow-up assessment were excluded.

Sample size and sampling: A target sample size of 100 was planned using consecutive sampling during the study period. Of 100 screened patients, 80 met eligibility criteria and had complete baseline and 90-day outcome data; these 80 participants constituted the final analytic sample.

Data collection and variables: After obtaining informed consent, a structured proforma was used to record demographics (age, sex, residence), anthropometry (body mass index category), mechanism and place of fall, fracture site and laterality, and comorbidities. Osteoporosis-related and fall-related risk factors were captured, including prior falls in the past 12 months, previous fragility fracture history, smoking/alcohol use, chronic corticosteroid exposure (≥3 months), early menopause in women, visual impairment, sedative use, and home environmental hazards. Fractures were classified using standard radiographs; hip fractures were categorized as intertrochanteric or femoral neck.

Bone health evaluation: Dual-energy X-ray absorptiometry (DXA) reports obtained previously or during admission/follow-up were recorded when available. Osteoporosis was defined as T-score ≤ −2.5 and osteopenia as T-score between −1.0 and −2.5 [8]. Serum 25-hydroxyvitamin D testing was performed when feasible; deficiency was defined as <20 ng/mL and insufficiency as 20–29 ng/mL [8].

Management and outcomes: Treatment modality was categorized as operative or conservative based on fracture site and clinical indications. Osteoporosis-specific therapy at discharge was documented (calcium/vitamin D alone versus calcium/vitamin D plus antiresorptive or other osteoporosis medication) in line with guideline-based secondary prevention principles [5,8]. Short-term outcomes included length of hospital stay (for admitted patients), early mobilization within 48 hours in hip fracture admissions, in-hospital complications (surgical site infection, pneumonia/respiratory infection, venous thromboembolism, pressure sore, delirium), 30-day readmission, 90-day mortality, and mobility status at 90 days (independent ambulation with or without stick, requires walker/assistance, non-ambulatory) [4].

Statistical analysis: Data were entered in Microsoft Excel and analyzed using standard statistical software. Continuous variables were summarized as mean ± standard deviation and categorical variables as number (percentage). Where comparisons were required (hip versus non-hip fractures), proportions were reported descriptively due to the modest sample size.

Ethical considerations: The study followed the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants, and confidentiality was maintained throughout the study.

During the 8-month study period, 100 adults aged ≥50 years with suspected low-energy fractures were screened. Eighty participants fulfilled eligibility criteria and completed short-term follow-up; these 80 were included in the analysis.

Participant characteristics are summarized in Table 1. The mean age was 67.2 ± 9.1 years (range 50–89), and women constituted 72.5%. Most participants belonged to the 60–69 year age band (37.5%). Slip or fall at home was the commonest mechanism (70.0%).

Table 1. Baseline characteristics (n = 80)

The anatomical distribution of fragility fractures is shown in Table 2. Hip fractures (proximal femur) were the most frequent (37.5%), followed by distal radius fractures (22.5%) and vertebral compression fractures (17.5%). Overall, 77.5% of fractures involved typical osteoporotic sites (hip, vertebrae, wrist). Among hip fractures, intertrochanteric fractures were more common than neck of femur fractures (63.3% vs 36.7%). For limb fractures (n = 66), right-sided injuries predominated (54.5%).

Figure : 1. Anatomical pattern of fragility fractures (n = 80)

Table 2. Anatomical pattern of fragility fractures (n = 80)

Table 3 summarizes the prevalence of osteoporosis- and fall-related risk factors. Most participants had multiple coexisting risk factors. Physical inactivity or low mobility (62.5%) and inadequate calcium/vitamin D intake or low sun exposure (60.0%) were frequent. A history of falls in the preceding 12 months was reported by 52.5%, and 22.5% had a previous fragility fracture.

Table 3. Risk factors among participants (n = 80)

Bone health evaluation was available for a subset of participants. DXA reports were available for 52 participants (65.0%); osteoporosis (T-score ≤ −2.5) was detected in 61.5% and osteopenia in 34.6%. Serum 25-hydroxyvitamin D results were available for 46 participants (57.5%), with deficiency (<20 ng/mL) in 60.9% and insufficiency in 26.1%.

Treatment patterns by fracture site are presented in Table 4. Operative management predominated for hip fractures (83.3%), whereas wrist, vertebral, and pelvic insufficiency fractures were managed mainly by conservative approaches. Overall, 46.3% underwent operative treatment. Osteoporosis-specific therapy beyond calcium and vitamin D was initiated at discharge in 55.0%.

Table 4. Treatment modality by fracture site (n = 80)

Figure 2: Treatment Modality by Fracture Site

Short-term outcomes are detailed in Table 5. Mean hospital stay among admitted cases was 6.2 ± 3.4 days, and was longer for hip fractures than non-hip fractures (8.1 ± 3.6 vs 4.9 ± 2.4 days). Early mobilization within 48 hours was achieved in 21 of 30 hip fracture patients (70.0%). Overall, 22.5% experienced at least one complication; delirium (7.5%) and respiratory infections (6.3%) were among the common complications. Thirty-day readmission occurred in 8.8% and 90-day mortality in 3.8%. At 90 days, 57.5% achieved independent ambulation, while 31.3% required a walker or assistance. Functional recovery was poorer after hip fractures than non-hip fractures, with independent ambulation in 40.0% versus 68.0%, respectively.

Table 5. Short-term outcomes (n = 80)

This study describes the pattern of fragility fractures among adults aged ≥50 years treated at a tertiary orthopaedic service in southern India. The predominance of women and the concentration of cases in the seventh decade are consistent with the recognized rise in osteoporotic fracture risk with age and postmenopausal bone loss [1,2]. Hip fractures were the most frequent injuries, followed by distal radius and vertebral compression fractures, mirroring the typical distribution of major osteoporotic fractures used in risk prediction frameworks such as FRAX [1,3]. Intertrochanteric fractures outnumbered femoral neck fractures, a pattern often seen in older, frailer populations.

Falls at home accounted for most injuries, highlighting an actionable prevention target. More than half of participants reported a fall in the previous year and over one-third reported home environmental hazards. These findings reinforce that fracture prevention requires dual attention to bone strength and fall exposure. Early functional recovery was poorer after hip fractures than non-hip fractures, underlining the early disability associated with hip injuries and the need for structured rehabilitation and safe home transition.

Our cohort showed a high prevalence of modifiable osteoporosis-related risk factors, including physical inactivity and low calcium/vitamin D exposure. Vitamin D deficiency was common among those tested, consistent with reports in adult fracture populations [6]. The broader evidence base indicates that fracture prevention from vitamin D supplementation is context-dependent; benefits are most plausible when deficiency is corrected and when calcium intake is adequate, while routine supplementation in unselected adults has limited fracture-preventive effect in meta-analyses [9-11]. Prior fragility fracture history in nearly one-quarter of participants is clinically important, as a prior fracture confers a sustained increase in future fracture risk and supports prioritization for secondary prevention [12].

Only a little over half of participants were started on osteoporosis-specific pharmacotherapy at discharge. Persistent treatment gaps after sentinel fragility fractures have been documented globally, even in centers with established orthopaedic pathways [14]. Guideline-based care recommends systematic osteoporosis evaluation and, for most patients with hip or vertebral fragility fractures, pharmacologic therapy unless contraindicated [5,8]. Embedding a standardized post-fracture pathway (discharge checklist, testing strategy, and early follow-up) and adopting a fracture liaison service model can improve initiation and continuity of evidence-based therapy.

Complication rates in this cohort were in line with expected early medical morbidity after fragility fractures, particularly among hip fracture admissions [4]. Although short-term mortality was low, hip fracture carries substantial excess mortality over longer follow-up, emphasizing the importance of multidisciplinary care beyond the index hospitalization [4].

Limitations

This single-center study used a modest analytic sample and relied on consecutive hospital presentation, limiting external validity to community-dwelling adults. DXA and 25-hydroxyvitamin D testing were unavailable for all participants, restricting interpretation of bone health status. Follow-up was limited to 90 days, so late mortality, refracture, and long-term functional outcomes were not captured. Risk factor assessment used history-based measures without validated fall-risk scales

In adults aged ≥50 years presenting with low-energy fractures, hip fractures formed the largest subgroup, with distal radius and vertebral compression fractures contributing substantially. Women were affected disproportionately, and most injuries followed a slip or fall at home. Participants commonly had clustered risk factors, particularly physical inactivity, prior falls, and poor calcium/vitamin D exposure, and osteoporosis and vitamin D deficiency were frequent among those evaluated. Short-term outcomes showed a meaningful complication rate and poorer early mobility after hip fractures, with lower independent ambulation at 90 days. Fracture care should integrate early rehabilitation with secondary prevention, including fall-risk mitigation and timely osteoporosis assessment and treatment at first contact and discharge

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