Fig. 1.

Summary of the clinical features and pathophysiology of skeletal fragility in diabetes. Numerous diabetes-related clinical characteristics are associated with increased fracture risk, although the independent contributors are difficult to ascertain because of significant clinical overlap. The contributing pathophysiological mechanisms are multifactorial, with many overlapping and sometimes conflicting effects. BMD is affected in diabetes (low in type 1 diabetes, normal/near-normal in type 2 diabetes) yet underestimates fracture risk compared with the general population for the same BMD level. Rather, impaired bone microarchitecture and low bone turnover result in impaired strength loading, suggesting a maladaptive response despite skeletal loading. HR-pQCT, high-resolution peripheral quantitative computed tomography; ROS, reactive oxygen species; T1D, type 1 diabetes; T2D, type 2 diabetes. This figure is available as part of a downloadable slideset