Osteoporotic fractures are a major worldwide epidemic. Here, we review global variability, ethnic differences and secular changes in osteoporotic fractures. Worldwide, age-standardized incidence rates of hip fracture vary >200-fold in women and >140-fold in men when comparing the country in which incidence rates are the highest with that in which they are the lowest. Median age-standardized rates are highest in North America and Europe, followed by Asia, Middle East, Oceania, Latin America and Africa. Globally, rates of hip fracture are greater in women than in men, with an average ratio of ∼2:1. The incidence of radiographic vertebral fractures is much higher than that of hip fractures, whereas the incidence rates of clinical vertebral fractures mirror hip fracture rates in most countries. Methodological challenges of defining and ascertaining vertebral fractures limit the interpretation of these data. Secular declines in hip fracture rates have been reported in populations from North America, Europe and Oceania. These declines are especially notable in women, suggesting that reproductive factors might contribute to this reduction. By contrast, hip fracture rates are increasing in parts of Asia and Latin America. Global indicators of health, education and socioeconomic status are positively correlated with fracture rates suggesting that lifestyles in developed countries might contribute to hip fracture. Improvements in fracture assessment, in particular for nonhip fractures, and identification of factors that contribute to this variability might substantially influence our understanding of osteoporotic fracture aetiology and provide new avenues for prevention.