Musculoskeletal

Osteoporosis

A systemic loss of bone strength that is usually silent until a fragility fracture, assessed with clinical fracture risk and bone density and managed with falls prevention, risk-appropriate bone protection and planned treatment follow-up.

In a nutshell

Osteoporosis is usually silent until a fragility fracture. Assess absolute fracture risk with FRAX or QFracture, add DXA when it will change classification or treatment, and look for vertebral fractures and secondary causes. Prevent falls and optimise calcium and vitamin D; use a risk-appropriate antiresorptive, and plan denosumab continuation or follow-on therapy before starting it.

Classic presentation

An older person sustains a hip, vertebral or wrist fracture after a fall from standing height or less, with no preceding bone pain, or is found to have vertebral height loss and multiple fracture-risk factors.

Key points

Fragility fracture is a high-risk event and should trigger fracture liaison assessment, falls prevention and timely secondary-fracture prevention.
Use FRAX or QFracture before DXA in most risk assessments; DXA refines risk near a treatment threshold and helps guide treatment in higher-risk patients.
A T-score at or below minus 2.5 supports densitometric osteoporosis in the relevant adult populations, but fracture history and clinical risk can justify treatment decisions above or without that threshold.
Use oral or intravenous bisphosphonate treatment when risk and clinical circumstances meet NICE or NOGG criteria; choose jointly and follow the BNF.
Denosumab is not a drug-holiday medicine: do not delay or stop it without a planned follow-on antiresorptive strategy.
Romosozumab is a specialist option with narrow NICE criteria; after an anabolic agent, start an antiresorptive without delay.
If prolonged high-dose glucocorticoids are planned, assess and protect bone at the start rather than waiting for a DXA result.
Review falls, adherence, fracture recurrence, dental symptoms and thigh or groin pain during long-term treatment.

First-line investigation

Clinical fracture-risk assessment with FRAX or QFracture, followed by DXA when indicated and targeted vertebral imaging or secondary-cause tests when clinically relevant.

Management

Respond to fragility fracture

Arrange fracture liaison or equivalent multidisciplinary assessment, urgent hip-fracture care where relevant, secondary-cause review, falls prevention and timely treatment to prevent another fracture.^2,3

Estimate risk and refine with DXA

Use FRAX or QFracture within the permitted age range, add DXA when risk is near an intervention threshold or treatment selection needs BMD, and assess vertebral fractures when height loss, kyphosis or risk factors suggest them.^1,2

Prevent falls and correct calcium or vitamin D insufficiency

Encourage weight-bearing and muscle strengthening, smoking cessation, moderate alcohol, a balanced diet and sufficient calcium and vitamin D, supplementing or correcting deficiency when needed.^2,6

Start risk-appropriate antiresorptive treatment

Offer an oral or intravenous bisphosphonate when NICE or NOGG criteria are met, choosing jointly after considering renal, gastrointestinal, administration, adherence and preference factors.^4,2,6

Use denosumab and anabolic therapies safely

Use denosumab only with a long-term continuation and follow-on plan; refer very-high-risk people for specialist anabolic or romosozumab assessment and follow anabolic treatment with an antiresorptive.^5,7,2,6

Review duration, adherence and rare harms

Review treatment tolerance, adherence, new fractures, dental symptoms and thigh or groin pain; reassess bisphosphonate duration and never create an unplanned denosumab interruption.^2,4,6

Exam traps

Osteoporosis is often asymptomatic; bone pain suggests fracture or another diagnosis rather than uncomplicated low bone density.
Do not order DXA routinely without prior risk assessment, except when a specific high-risk context makes immediate assessment appropriate.
A T-score alone does not capture all fracture risk; previous vertebral fracture, glucocorticoids and secondary causes can make FRAX underestimate risk.
Denosumab must not be stopped or delayed without a follow-on antiresorptive plan because rebound bone turnover can cause multiple vertebral fractures.
Romosozumab is not a general first-line drug; apply current NICE eligibility and cardiovascular safety criteria.
A bisphosphonate pause is a risk-based review decision, not an automatic step after a fixed duration.
New thigh or groin pain on long-term antiresorptive therapy needs assessment for atypical femoral fracture.

Illustrations

Trabecular bone lossComparative diagram of normal dense trabecular bone against thinned and perforated osteoporotic trabecular struts, with cortical thinning shown separately.PassFinals · original

Vertebral wedge fractureLateral spine radiograph showing anterior wedging of a vertebral body due to an osteoporotic compression fracture.James Heilman, MD, Wikimedia Commons · CC-BY-SA-4.0

Exaggerated thoracic kyphosisClinical image illustrating thoracic kyphosis after vertebral fractures, with a note that height loss and kyphosis should prompt vertebral-fracture assessment.Fae, Wikimedia Commons · CC-BY-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.