The Second Fracture Can Be Prevented: Bone Health and Secondary Prevention After Fragility Fracture

Too many fragility fractures are still treated as isolated mechanical failures: fix the fracture, mobilise the patient, send the discharge summary, move on. That mindset is no longer defensible. A fragility fracture is a sentinel event. It identifies a patient with a substantially elevated risk of another fracture, especially in the next two years. For the orthopaedic team, the job is not only to stabilise the bone that has broken. It is also to help prevent the next one.

Fast Takeaways

• Any minimal-trauma fracture in a person over 50 should trigger bone health assessment and a secondary prevention plan.
• The refracture risk is highest early, which is why delayed outpatient follow-up alone is often inadequate.
• Fracture liaison services and strong discharge communication close one of the biggest care gaps in musculoskeletal medicine.
• Current Australian guidance emphasises FRAX-based risk assessment, denosumab timing awareness, and earlier anabolic thinking in very high-risk patients.
• Orthopaedic surgeons do not have to personally run lifelong osteoporosis care, but they should not let the patient leave the system without the pathway being activated.

Why This Matters in 2026

The 2024 RACGP and Healthy Bones Australia guideline, published in the Medical Journal of Australia in 2025, makes the refracture story explicit. The concept of “imminent” and very high fracture risk matters because the first 24 months after an incident fracture are a high-risk window. That is exactly the period where secondary prevention should be decisive.

Australian quality standards reinforce the same point. The Hip Fracture Clinical Care Standard requires a falls and bone health assessment and management plan before the patient leaves hospital, with referral for secondary fracture prevention where appropriate. That is not optional extra work. It is core quality care.

The Core Decision Points

1. Recognise the fracture as a diagnosis, not just an injury

A low-energy fragility fracture means the patient has declared themselves at risk. Even if bone mineral density has not yet been formally measured, the event itself should change management thinking.

For the orthopaedic team, that means asking:

• was this truly a minimal-trauma event?
• has the patient fractured before?
• are they already on bone-active therapy?
• is there an FLS pathway or clear GP handover?

2. Use risk tools, but do not hide behind them

The updated Australian guidance places real value on fracture risk tools, particularly FRAX, for stratification. But a patient older than 50 with a minimal-trauma fracture already deserves action. The tool should help refine urgency and longer-term planning, not delay recognition of risk.

3. Identify the very high-risk patient early

The 2024 Australian guidance highlights very high-risk features such as:

• recent fracture
• multiple fractures
• very low T-score
• fracture while already on therapy
• high FRAX major osteoporotic fracture risk

This matters because anabolic-first thinking is increasingly relevant in patients at the highest risk, especially when the refracture window is short.

4. Respect the denosumab problem

One of the most important practical updates in modern bone health care is the recognition of rebound vertebral fracture risk after denosumab cessation. If a patient is on denosumab or is being started on it, the follow-up plan must be explicit. “We will sort it out later” is not a safe transition strategy.

Common Pitfalls

Assuming bone health is “the GP’s job”

Long-term management may sit with general practice or specialist metabolic bone care, but activation of the pathway often begins with the orthopaedic admission.

Forgetting that the refracture clock starts immediately

Secondary prevention is most valuable when it begins early, not months later once the fracture clinic story is over.

Starting or stopping therapy without a plan

This is especially relevant for denosumab, where poor transition planning can be harmful.

Missing falls risk and functional contributors

Medication review, strength, balance, nutrition, cognition, and home risk are part of secondary prevention too.

Exam and Practice Pearls

• If an examiner asks what should happen before discharge after hip fracture, mention a falls and bone health plan plus referral for secondary fracture prevention.
• Quote the broad Australian principle that patients older than 50 with a minimal-trauma fracture should be assessed and appropriately treated.
• Use osteoporosis as the parent condition, not just the complication of the day.
• If discussing denosumab, mention rebound vertebral fracture risk after cessation and the need for planned follow-on therapy.

References

1. Wong PKK, Center JR, Eisman JA, et al. 2024 Royal Australian College of General Practitioners and Healthy Bones Australia guideline for osteoporosis management and fracture prevention in postmenopausal women and men over 50 years of age. Medical Journal of Australia. 2025.
2. Healthy Bones Australia guideline PDF. 2024.
3. Information for clinicians - Hip Fracture Clinical Care Standard. Australian Commission on Safety and Quality in Health Care.
4. Fragility fractures fact sheet. World Health Organization. 2024.