Encouraging recovery or avoiding risk? A proposed clinical framework for rehabilitation decision-making after fragility fractures.

Fragility fractures are a major cause of morbidity, functional decline, and loss of independence in older adults. Although surgical management restores structural stability, postoperative outcomes are strongly influenced by the timing, intensity, and quality of rehabilitation. Contemporary guidelines advocate early mobilization, timely weight-bearing, and multidisciplinary orthogeriatric care; however, rehabilitation practice often remains overly cautious. Despite increasing evidence supporting early mobilization after fragility fractures, clinical rehabilitation pathways remain highly variable, contributing to delayed recovery, increased complications, prolonged hospitalization, and reduced quality of life. This narrative review synthesizes current evidence on rehabilitation after fragility fractures and examines the persistent gap between evidence-based recommendations and real-world clinical practice. In addition, the review proposes a structured clinical decision-making framework designed to bridge the gap between evidence and orthopedic rehabilitation practice. A structured literature search was conducted across PubMed, Scopus, Web of Science, Google Scholar, and EBSCO for studies published between 2015 and 2025. Priority was given to systematic reviews, meta-analyses, and randomized controlled trials addressing early mobilization, orthogeriatric co-management, fall prevention, and emerging rehabilitation strategies. The findings indicate that risk-averse rehabilitation practices are driven by interacting clinician-, patient-, and system-level factors. Clinician concerns about fixation stability, patient-related barriers such as pain, fear of falling, and cognitive impairment, and system-level constraints including limited geriatric rehabilitation pathways contribute to delayed mobilization. Based on these findings, a clinical framework integrating fixation stability, medical readiness, functional capacity, and environmental support is proposed to guide progressive and individualized rehabilitation after fragility fractures.