An international review sets out what is already established for fragility fracture care - timely surgery, orthogeriatric input, early mobilisation, unrestricted weight-bearing, and secondary fracture prevention - and asks why it is still not delivered. In high-income systems, international quality standards and registry audits have converted that evidence into measurable indicators, and care has improved where they are used.
In low- and middle-income countries the barrier is identified as health-system constraint rather than absent evidence: workforce shortages, late presentation, limited infrastructure and fragmented pathways. The authors argue that quality standards can be adapted to local context without losing their clinical core, and that emerging programmes show this is achievable rather than aspirational.
This is a perspective piece, not a study, and it produces no effect estimate to weigh. Its value is in naming the lever. For an Indian orthopaedic department the specific implications are unglamorous and within reach: a written fragility fracture pathway, someone accountable for secondary prevention before discharge, unrestricted weight-bearing as the default order rather than an exception, and an audit that counts what actually happened. None of that requires new evidence or new equipment.
- Make unrestricted weight-bearing the default postoperative order and document any deviation.
- Name one person responsible for starting secondary fracture prevention before discharge.
- Start an audit with two numbers - time to surgery and proportion started on bone protection - before attempting anything larger.
- Adapt an existing international quality standard rather than writing a local one from scratch.
- Treat late presentation as a pathway problem to measure, not as a patient characteristic to accept.
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