Risk & fractures

A silent disease

There is no ache that tells you bone is thinning. People often feel entirely well right up until a bone breaks — which is precisely what makes osteoporosis dangerous. Nowhere is this clearer than in the spine: vertebral fractures are the most common osteoporotic fracture, yet many cause little or no pain and are never diagnosed. In North America, reported rates of undiagnosed vertebral fractures in postmenopausal women with osteoporosis run as high as 45%. Slowly lost height, a stooped posture, or new mid-back pain can be the only clues.

This silence is why so many people are diagnosed too late, and why screening and vertebral imaging matter (see imaging). A DXA scan and, when indicated, a look at the spine can find the disease before it costs you a bone.

Fracture sites & consequences

Fragility fractures — breaks that occur from a fall from standing height or less — cluster at a few characteristic sites, each with its own story.

The scale is easy to underestimate: more fractures occur each year from osteoporosis than heart attacks, strokes, and breast and prostate cancers combined. The consequences range from an inability to perform basic tasks and chronic pain to the need for assisted living — and, after a hip fracture, a measurable increase in the risk of death.

The refracture cascade

One fracture makes the next far more likely — and soon. Prior fracture is one of the strongest predictors of future fracture, partly independent of bone density, and the risk climbs with each additional fracture. Crucially, risk is front-loaded: it is highest in the first 1–2 years after a break. This is the concept of imminent risk, and it is the reason a recent fracture is treated as an emergency for the skeleton, not something to address "eventually."

Yet the system routinely fails here. More than two-thirds of postmenopausal women with a fragility fracture never receive an osteoporosis diagnosis, and in one large study fewer than 20% of men and postmenopausal women with an osteoporosis-related fracture were treated within two years. Many are never referred for follow-up at all. A broken bone after 50 should start a plan — not just heal and be forgotten.

Who is at very high risk

Guidelines now separate high risk from very high risk, because the highest-risk patients benefit from more aggressive, bone-building-first treatment (see sequencing). About 35% of postmenopausal women over 50 fall into the high-to-very-high category. Features that mark very high (and often imminent) risk include:

• A recent fracture (within the past 12 months).
• Multiple prior fractures.
• A fracture that occurred while on osteoporosis therapy.
• A very low bone-density T-score (e.g., well below −2.5), or fractures plus low BMD.
• High FRAX probability — 10-year hip fracture risk above ~4.5% or major osteoporotic fracture risk above ~30%.
• A high risk of falls or a history of injurious falls.

If any of these describe you, it changes the conversation — both the urgency to treat and, often, which treatment to start with. See risk stratification and treatment.