Osteoporosis is a silent disease with increasing prevalence due to the global ageing population. Decreased bone strength and bone quality is the hallmark of osteoporosis which leads to an increased risk of fragility fractures in elderly. It has been estimated that approximately ~50% of women will suffer during their lifetime from an osteoporotic fracture. This must be considered as a major health concern, as it has previously been established that fragility fracture has been associated with decreased quality of life due to increased disability, more frequent hospital admission and most importantly, osteoporotic fractures have been related to an augmented mortality risk. Anti-osteoporotic drugs are available for improving bone quality. Although there is access to these therapeutic options, there remain multiple unmet needs in the field of osteoporosis and fracture care, for example, the primary prevention of osteoporosis in young individuals (to reach a high peak bone mass), the optimization of the use of imaging techniques [dual-energy X-ray absorptiometry (DXA), vertebral fracture assessment (VFA) and new techniques measuring bone quality], the use of nonmedical treatment options and surgical techniques of fracture healing. In this review, we will discuss topics that play a role in the occurrence and prevention of fractures, and we give an overview of and insight into the critical issues and challenges around osteoporosis and fracture prevention.