Context:Non-hip non-vertebral fractures represent half of all osteoporotic fractures, however their contribution to the burden of re-fracture and premature mortality is unclear.Objectives:To examine the risk and burden of subsequent fracture and mortality associated with an initial non-hip non-vertebral fracture.Design:Prospective cohort from the Dubbo Osteoporosis Epidemiology Study 1989-2010.Setting and Participants:Community dwelling participants aged 60+ with incident fracturesOutcome Measures:Relative risk of all subsequent fractures and age adjusted standardized mortality ratios according to initial fracture type. The total burden of adverse events was assessed using competing risk models with 4 potential outcomes: mortality following initial fracture, mortality following subsequent fracture, subsequent fracture and alive, event-free.Results:Of the 952 fractures in women and 343 in men, over half were non-hip non-vertebral fractures (486 in women and 173 in men). Non-hip non-vertebral fracture were associated with increased risk of any subsequent fracture [1.95 (1.67- 2.27) for women and 2.47 (1.82- 3.35) for men, hip re-fracture [2.11 (1.04- 4.28) for women and 2.63 (1.35- 5.13) for men] and vertebral re-fracture [1.89 (1.43- 2.48) for women and 2.13 (1.20- 3.79) for men]. More importantly, non-hip non-vertebral fractures were associated overall with 20% excess mortality for the first 5 years post-fracture, of which half was due to initial fracture and the remaining due to subsequent fractures. Proximal fractures were associated with increased mortality risk per se, while distal fractures were associated with increased mortality risk only in the group who sustained subsequent fractures.Conclusion:Non-hip non-vertebral fractures are associated with significant risk of subsequent fracture including hip and vertebral re-fracture, and premature mortality. Due to their high prevalence, about half of all subsequent fractures and a quarter of all fracture-related excess mortality were attributable to non-hip non-vertebral fracture. Thus non-hip non-vertebral fracture warrants early investigation and appropriate intervention.