A 3-year prospective study was performed to evaluate the incidence of fractures in institutionalized elderly and associated risk factors. A total of 197 subjects (47 males and 150 females, mean age 81.5 +/- 8.0 years) were included in the study. The annual fracture incidence was 7.8%. All hip fractures occurred in female subjects (annual incidence = 3.7%). As expected, the incidence of fractures is higher in walking subjects. In walking subjects (n = 128) logistic regression analysis showed falls [adjusted relative risk (RR) = 3.3; 95% confidence interval (CI) = 1.3-8.4] and age (adjusted RR = 1.7; 95% CI = 1.1-2.3) to be variables independently and significantly associated with fractures, after adjusting for baseline bone mineral density (BMD) and sex. Hip fractures were associated with age (RR = 1.6; 95% CI = 1.1-2.3), and non-hip fractures with falls (RR = 4.1; 95% CI = 1.3-13.4). The importance of low BMD as a risk factor for fractures is reduced in the institutionalized elderly. However, other fracture-site-specific risk factors exert a greater influence.