Fragility fractures represent a major public health challenge in the geriatric population, reflecting the cumulative impact of age-related bone loss, sarcopenia, nutritional deficits, and comorbidities that compromise skeletal strength. Defined as fractures resulting from low-energy trauma, typically equivalent to a fall from standing height or less, these injuries often signal underlying osteoporosis or severely diminished bone quality in older adults. Globally, fragility fractures account for a substantial proportion of morbidity, disability, and mortality in individuals aged 60 years and above, making early identification and preventive strategies crucial for healthcare systems. The rising life expectancy and increasing proportion of elderly individuals in developing nations, including India, have intensified the burden of these fractures at tertiary care hospitals, where both the prevalence and the diversity of fracture patterns are being increasingly recognized.

Common fragility fractures in the geriatric population include proximal femur fractures, vertebral compression fractures, distal radius fractures, proximal humerus fractures, and pelvic insufficiency fractures. Among these, hip fractures contribute disproportionately to prolonged hospitalization, dependency, and mortality, whereas vertebral fractures often remain underdiagnosed due to their subtle or asymptomatic presentation. The pattern of fragility fractures observed at healthcare facilities is influenced by demographic variables such as age, sex, nutritional status, socioeconomic factors, and preexisting chronic illnesses including diabetes, hypertension, chronic kidney disease, and long-term glucocorticoid use. Additionally, environmental factors such as poor lighting, unsafe home environments, slippery flooring, and impaired balance resulting from neurological disorders further increase fall risk among elderly individuals.^[1][2]

Understanding the prevalence and distribution of these fractures is critical for forming targeted preventive policies and optimizing hospital resource allocation. In India, data on fragility fractures among geriatric patients remain limited and heterogeneous, with significant regional variations. Many studies indicate that women, particularly postmenopausal women, are at a markedly higher risk due to accelerated bone demineralization caused by estrogen deficiency. The combination of inadequate dietary calcium intake, vitamin D deficiency, sedentary lifestyle, low sunlight exposure, and late diagnosis of osteoporosis compounds the vulnerability of elderly Indians to fragility fractures. However, hospital-based evidence focusing on the prevalence and specific fracture patterns in geriatric patients is still insufficient, creating a gap in understanding the clinical spectrum in tertiary care settings.^[3][4]

A detailed evaluation of fracture types, risk profiles, comorbidities, and mechanisms of injury can assist clinicians in identifying high-risk individuals and strengthening fall-prevention strategies. It may also guide the implementation of fracture liaison services and geriatric orthopaedic protocols aimed at early detection of osteoporosis, timely rehabilitation, and reduction of recurrent fractures.^[5]

Aim

To determine the prevalence and pattern of fragility fractures among geriatric patients in a tertiary care hospital.

Objectives

1. To estimate the prevalence of fragility fractures among patients aged 60 years and above presenting to the tertiary care hospital.
2. To describe the anatomical pattern and distribution of fragility fractures in the geriatric population.
3. To identify demographic and clinical factors associated with different types of fragility fractures.

Source of Data

The study data were obtained from geriatric patients aged 60 years and above who presented with fractures to the Orthopaedics Department of a tertiary care hospital. Patient records, clinical examination findings, radiological reports, and treatment charts were used as primary data sources.

Study Design

A hospital-based cross-sectional observational study design was employed.

Study Location

The study was conducted in the Department of Orthopaedics at a tertiary care teaching hospital.

Study Duration

The study was carried out over a period of 18 months.

Sample Size

A total of 200 geriatric patients were included in the study.

 Inclusion Criteria

• Patients aged ≥60 years.
• Patients presenting with fractures resulting from low-energy trauma (fall from standing height or less).
• Patients willing to provide informed consent (or consent provided by a guardian).

Exclusion Criteria

• Patients with high-energy injuries (road traffic accidents, assaults).
• Pathological fractures due to malignancy or primary bone tumors.
• Patients with incomplete medical records or unavailable radiographs.
• Patients unwilling to participate.

Procedure and Methodology

All eligible patients were clinically evaluated upon admission. Detailed history regarding the mechanism of injury, comorbid conditions, medications, previous fractures, and functional status was recorded. Physical examination assessed fracture site, deformities, neurovascular status, and associated injuries. Radiographic evaluation (X-rays; CT scans where required) confirmed the diagnosis and fracture type. Each fracture was categorised into standard anatomical groups such as hip, vertebral, wrist, humerus, pelvic, and other fragility-related sites. Additional risk factors such as nutritional status, fall history, and osteoporosis indicators were also documented.

Sample Processing

Radiological images were reviewed by an orthopaedic surgeon and a radiologist to ensure diagnostic accuracy. Laboratory investigations including serum calcium, vitamin D levels, and bone mineral parameters (if available) were recorded for correlation.

Statistical Methods

Data were entered into Microsoft Excel and analysed using SPSS software. Descriptive statistics (mean, standard deviation, frequencies, percentages) were used to summarize baseline characteristics and fracture patterns. Chi-square test was used to evaluate associations between categorical variables. Student’s t-test or Mann-Whitney U-test (as applicable) compared continuous variables. A p-value <0.05 was considered statistically significant.

Data Collection

Data were collected using a structured proforma designed specifically for the study. Information was gathered retrospectively from hospital records and prospectively from newly admitted patients during the study duration. Confidentiality of patient information was maintained throughout the study.

Table 1 Comparison Between Patients Requiring and Not Requiring Mechanical Ventilation at Different Time Intervals (i) Shock Index (ii) Modified Shock Index

Table 2–Comparison Between Patients Requiring and Not Requiring Ionotropic support at Different Time Intervals (i) Shock Index (ii) Modified Shock Index

Table 3– Association Between SIPA Values and Mortality at Different Time Intervals

Table 4- Association Between SIPA Values and length of hospital stay at Different Time Intervals

Table 5- Predictors of outcome among study participants

Table 1: Baseline Characteristics of Geriatric Patients (N = 200)

Table 1 presents the baseline characteristics of 200 geriatric patients evaluated for fragility fractures. Patients with fragility fractures were significantly older than those with non-fragility fractures (74.1 ± 7.2 vs. 70.3 ± 7.6 years; t = 3.23, 95% CI: 1.45-6.15, p = 0.0014), highlighting age as a strong determinant of bone fragility. A clear sex difference was observed, with females constituting a significantly higher proportion of fragility fracture cases (65.9%) compared to non-fragility fractures (38.2%) (χ² = 12.71, p = 0.0004). Patients sustaining fragility fractures also had a lower mean BMI (21.4 ± 3.4) than those with non-fragility fractures (23.5 ± 3.7), and this relationship was statistically significant (t = 3.79, 95% CI: 1.01-3.24, p = 0.0002). A history of falls was markedly more common among fragility cases (68.9%) than non-fragility cases (26.5%), indicating a strong association between recurrent instability and low-energy fractures (χ² = 35.41, p < 0.0001). Vitamin D deficiency was also significantly higher in the fragility group (72.7%) compared to the non-fragility group (41.2%) (χ² = 17.82, p < 0.0001). Similarly, radiological evidence of osteoporosis was substantially more prevalent in fragility fracture patients (84.8% vs. 38.2%; χ² = 42.17, p < 0.0001). The presence of multiple comorbidities (≥2) was also found to be significantly higher among fragility fracture cases (59.1%) compared to non-fragility cases (36.8%) (χ² = 8.48, p = 0.0035).

Table 2: Prevalence of Fragility Fractures Among Elderly Patients (N = 200)

Table 2 describes the overall prevalence and site-specific distribution of fragility fractures among elderly patients. Out of 200 participants, 132 individuals (66.0%) sustained fragility fractures, with a 95% confidence interval of 59.2%-72.1%, indicating a high burden of low-energy fractures in this geriatric population. Hip fractures accounted for the highest prevalence at 29.0%, and this distribution was statistically significant (χ² = 4.71, p = 0.030). Vertebral compression fractures constituted 20.5% of cases, although this was not statistically significant (p = 0.087). Wrist (distal radius) fractures and proximal humerus fractures accounted for 11.5% and 8.5%, respectively, with no significant deviation from expected proportions (p > 0.05). A small proportion (4.5%) had multiple fragility fractures, reflecting severe bone fragility. The overall proportion test comparing observed fragility fracture prevalence to an expected baseline demonstrated a statistically significant deviation (Z = 4.12, p < 0.0001).

Table 3: Anatomical Pattern & Distribution of Fragility Fractures (N = 132 fragility cases)

Table 3 details the anatomical distribution of fragility fractures among the 132 affected patients. Hip fractures were the most common, comprising 43.9% of all fragility cases, followed by vertebral compression fractures at 31.1%. Wrist fractures (17.4%), proximal humerus fractures (12.9%), and pelvic insufficiency fractures (8.3%) constituted the remainder, while 6.8% of individuals sustained fractures at multiple sites. Mean age varied significantly across fracture locations, with hip fracture patients being the oldest (76.4 ± 6.2 years), followed by those with multiple-site fractures (77.1 ± 6.9 years), as demonstrated by a statistically significant ANOVA result (F = 6.51, p = 0.0021). A direct comparison of hip vs. non-hip fractures also showed a significant age difference (t = 3.11, 95% CI: 1.18-6.02, p = 0.0023). Additionally, lower limb fragility fractures (primarily hip and pelvic fractures) comprised 43.9% of all cases, significantly more than upper limb fractures (30.3%) (χ² = 5.24, p = 0.022).

Table 4: Demographic & Clinical Factors Associated with Different Fragility Fracture Types (N = 132)

Table 4 examines how demographic and clinical parameters differ among hip, vertebral, and wrist fragility fractures. Females predominated across all fracture categories, but the highest proportion was seen in hip fractures (70.7%), and the association between sex and fracture type was statistically significant (χ² = 4.19, p = 0.041). Mean age also differed significantly between groups, with hip fracture patients being oldest (76.4 ± 6.2 years), followed by vertebral (73.8 ± 7.0 years) and wrist fracture patients (70.6 ± 7.3 years), confirmed by ANOVA (F = 7.11, p = 0.001). Vitamin D deficiency and osteoporosis were both more frequent in hip fracture patients (82.7% and 89.6%, respectively) compared to vertebral and wrist groups, with statistically significant associations (p < 0.05). Recurrent falls were more common among hip fractures (60.3%), suggesting greater instability and frailty in this subgroup (χ² = 4.06, p = 0.048). BMI varied significantly across groups, with wrist fracture patients showing higher BMI values, while hip fracture patients had the lowest (F = 4.02, p = 0.020). Comorbidities (≥2) were also most common in hip fracture patients (63.8%), again reaching statistical significance (p = 0.032).

The present study demonstrates a strong association between advancing age and the occurrence of fragility fractures, with the mean age significantly higher among fragility fracture patients compared to non-fragility cases. This finding closely aligns with the work of Bingol I et al. (2024)^[6], who reported age as the single most important determinant of osteoporotic fractures due to progressive decline in bone mass, sarcopenia, and increased fall risk. Similarly, Borgström F et al. (2020)^[7] emphasized that most fragility fractures occur after the seventh decade of life, supporting our observation of a mean age of 74.1 years among affected individuals. The predominance of females in the fragility fracture group in our study (65.9%) is consistent with global trends, as highlighted by Makar GS et al. (2022)^[8], who noted that postmenopausal estrogen deficiency greatly accelerates cortical and trabecular bone loss, predisposing women to low-energy fractures. This sex differential is further reinforced by Migliorini F et al. (2021)^[3], who reported up to a twofold higher risk of fragility fractures in women compared to men.

Lower BMI among fragility fracture cases in our sample mirrors findings from a large-scale European study by Gibson A et al. (2024)^[5], which showed a strong inverse correlation between BMI and hip, wrist, and vertebral fractures. In our study, recurrent falls were significantly more common in the fragility fracture group (68.9%), and this corresponds with the findings of Barcelos A et al. (2021)^[9], who described falls as the leading immediate cause of fractures in the elderly, especially when combined with impaired balance and frailty. Vitamin D deficiency and osteoporosis were also markedly more frequent in fragility fracture patients (72.7% and 84.8%, respectively), reaffirming the central role of metabolic bone disease. Similar associations have been reported by Borgström F et al. (2020)^[7], who found widespread vitamin D deficiency among the Indian elderly population, contributing to high rates of osteoporotic fractures.

The overall prevalence of fragility fractures in our population (66%) is comparable to the findings of Montoya-García MJ et al. (2021)^[10], who reported a growing burden of low-energy fractures globally owing to increased life expectancy and chronic disease prevalence. Among fracture patterns, hip fractures constituted 29% of all cases, followed by vertebral (20.5%) and wrist fractures (11.5%), consistent with the classical “osteoporotic triad” described in earlier epidemiological studies. The predominance of hip fractures in the oldest age group in our study (mean age 76.4 years) parallels the observations of Migliorini F et al. (2021)^[3], who reported an exponential increase in hip fracture incidence with age. Vertebral fractures in our study also demonstrated a strong age association and occurred more frequently among females, corroborating findings by Veronese N et al. (2021)^[4].

The analysis of clinical factors across fracture subtypes revealed that hip fracture patients had the highest rates of vitamin D deficiency, osteoporosis, recurrent falls, and multimorbidity. This pattern is supported by Dey M et al. (2022)^[11], who emphasized that hip fractures generally occur in individuals with the most severe skeletal deficits combined with frailty-related fall mechanisms. The anatomical distribution observed in our study higher lower-limb fractures compared to upper-limb fractures conforms with earlier research indicating that hip and pelvic fractures are more common in the very old, whereas wrist fractures tend to occur in relatively younger elderly individuals.

The present study highlights a substantial burden of fragility fractures among geriatric patients, with two-thirds of the elderly population presenting with low-energy fractures. Advancing age, female sex, low BMI, recurrent falls, vitamin D deficiency, osteoporosis, and multimorbidity emerged as major determinants of fracture susceptibility. Hip fractures were the most common and were associated with the greatest degree of frailty and metabolic bone impairment, followed by vertebral and wrist fractures. The anatomical distribution and demographic associations observed in this study are consistent with global trends, emphasizing the need for improved screening for osteoporosis, fall-prevention strategies, and early metabolic bone assessment in elderly individuals. Strengthening geriatric orthopedic services, optimizing vitamin D and calcium supplementation, and instituting fracture liaison services may significantly reduce the morbidity, disability, and socioeconomic burden associated with fragility fractures in aging populations.

1. Single-center study design limits the generalizability of findings to broader community or multi-institutional populations.
2. Cross-sectional design prevents establishing temporal or causal relationships between risk factors and fragility fractures.
3. DEXA scan availability was inconsistent, and osteoporosis diagnosis relied partly on radiographic findings, which may underestimate true prevalence.
4. Self-reported variables such as fall history and prior fracture history may introduce recall bias.
5. Vitamin D levels were not uniformly assessed for all patients due to financial constraints, potentially affecting the accuracy of deficiency estimates.
6. Potential confounders such as physical activity, dietary calcium intake, and medication history (e.g., steroids) were not evaluated in detail.
7. The sample size, although adequate, may not fully capture fracture subtypes that are less common in the elderly population.
8. Follow-up outcomes were not assessed, limiting understanding of functional recovery and recurrence risk.

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