Every year in Canada, roughly 30,000 people have a hip fracture. The majority had osteoporosis before that fracture — and the majority leave hospital without being assessed for osteoporosis treatment. The second fracture is the one that changes lives permanently. Here's how to close that gap.
Research consistently shows that only 20% of Canadians who have a fragility fracture are assessed and treated for osteoporosis afterward. A fragility fracture is any fracture from a low-impact event — a fall from standing height or less, a cough, or even moving suddenly. If a fracture happens from that level of force, the underlying bone was already weakened by osteoporosis.
The scale of this gap is hard to overstate. Osteoporosis Canada's Osteoporosis: A Portrait of Canada report estimates that 80% of people who experience a fragility fracture have not been diagnosed with osteoporosis beforehand, and 80% of those who do experience a fracture are not subsequently treated. These two failure points — missed diagnosis and missed follow-up treatment — together explain why so many Canadians have a second fracture within two years of their first.
Secondary fracture prevention is the systematic effort to identify, assess, and treat osteoporosis in people who have already had a fragility fracture — before the second fracture happens. It involves three steps:
This sounds straightforward, but it requires coordination between the emergency department or orthopaedic team that treats the fracture and the family physician or specialist who manages the osteoporosis. That handoff fails most of the time in the current Canadian system — unless a Fracture Liaison Service is in place.
A Fracture Liaison Service (FLS) is a dedicated program within a hospital or health system that systematically identifies fragility fracture patients and coordinates follow-up osteoporosis assessment and treatment. The model was developed in the United Kingdom and has been adopted widely in Canada over the past 15 years.
FLS programs have been proven to significantly increase the proportion of fracture patients who receive osteoporosis investigation and treatment — in some programs, from the usual 20% to over 70%. They also reduce subsequent fracture rates and associated healthcare costs.
FLS programs vary in scope and resources across Canada. Some of the more established programs include:
If your hospital doesn't have a formal FLS, ask your orthopaedic surgeon or emergency physician to refer you for osteoporosis assessment before discharge or at follow-up. Don't assume it will happen automatically.
Not every fracture requires osteoporosis investigation — a broken hand from a sports injury in a healthy 35-year-old is a different situation. The clinical triggers for secondary fracture prevention investigation are:
| Fracture Type | Investigation Recommended? |
|---|---|
| Hip fracture (any age over 50) | Yes — highest priority |
| Vertebral fracture (spine) | Yes — especially if fragility-related or incidentally discovered |
| Wrist fracture (distal radius) after a fall | Yes — particularly in women over 50 |
| Shoulder fracture (proximal humerus) after a fall | Yes |
| Rib fracture from low-energy mechanism | Yes |
| Multiple stress fractures | Yes |
| High-energy fracture in young healthy adult (e.g., motor vehicle accident) | Usually not unless other risk factors present |
Osteoporosis investigation after a fragility fracture typically involves a DEXA bone density scan and a set of blood tests. The DEXA scan measures bone mineral density at the hip and spine, producing T-scores that classify bone density as normal, osteopenic, or osteoporotic. See our detailed guide to DEXA scans in Canada for what to expect.
Blood tests screen for secondary causes of low bone density — conditions like hyperparathyroidism, vitamin D deficiency, celiac disease, thyroid dysfunction, and kidney disease that can accelerate bone loss and need to be treated alongside osteoporosis. See our overview of secondary osteoporosis causes in Canada.
A FRAX score — a 10-year fracture risk calculation — is generated using the DEXA result and clinical risk factors. In Canada, this guides treatment decisions. See our fracture risk calculator to understand your risk score.
Following a fragility fracture, Osteoporosis Canada guidelines generally recommend starting osteoporosis medication rather than waiting for lifestyle measures to show effect — the fracture itself demonstrates that bone is already vulnerable to re-injury.
First-line treatment is typically an oral bisphosphonate (alendronate, generic available at most Canadian pharmacies for approximately $15–25/month). For patients who can't tolerate oral bisphosphonates, intravenous zoledronic acid (Reclast) given once yearly is an alternative and is covered under most provincial drug plans with prior approval.
For patients with severe osteoporosis or multiple fractures, bone-building medications like teriparatide (Forteo, or biosimilar Osnuvo) or romosozumab (Evenity) may be appropriate. See our guide to anabolic osteoporosis medications in Canada for details on these higher-tier options and Canadian coverage.
Osteoporosis medication works in combination with adequate calcium and vitamin D — not as a replacement for them. Osteoporosis Canada recommends 1,200mg calcium daily (from food and supplements combined) and 800–2,000 IU vitamin D daily for adults 50+ at risk. Most post-fracture patients should be supplementing both. See our calcium guide and vitamin D guide for specifics.
If you or a family member has had a fragility fracture, these questions should be part of every follow-up conversation:
If your family physician doesn't raise osteoporosis after you've had a wrist, hip, or vertebral fracture — bring it up yourself. The care gap exists because the system doesn't reliably prompt this conversation. Patients and families who ask get better care.
Post-fracture osteoporosis treatment is often covered, but coverage conditions vary by province:
| Province | Coverage Notes |
|---|---|
| Ontario (ODB) | Alendronate (Fosamax generic) listed; seniors and low-income fully covered; zoledronic acid requires prior authorization |
| BC (PharmaCare) | Alendronate covered; zoledronic acid covered for post-fracture patients with special authority; denosumab (Prolia) with special authority |
| Alberta (AHB) | Bisphosphonates and denosumab listed with criteria including prior fragility fracture or T-score ≤ -2.5 |
| Quebec (RAMQ) | Alendronate and risedronate listed; zoledronic acid covered with criteria |
Ask your pharmacist or prescribing physician to confirm coverage under your provincial plan and whether prior authorization paperwork is needed. Many patients delay treatment because coverage approval takes a few weeks — starting the process early matters.