Alcohol abuse is increasing in the UK and contributes significantly to the rising number of acute hospital admissions. The effects are increasingly seen among younger people who binge drink. The effects of excess alcohol on the skeleton have attracted far less attention than those on other organs, but the risk of fractures at important sites, such as the hips and vertebrae, is greatly increased in alcoholics. This is partly owing to reductions in bone mineral density, but other factors such as an increased rate of falls play an important part. The contribution of excess alcohol consumption to the risk of fractures is recognised in the widely available fracture assessment tool (FRAX). The mechanisms of fracture in alcohol abusers are complex and involve direct effects on bone cells, and indirect effects, mediated by alcohol, on the endocrine system, pancreas and cytokine system. Poor nutrition, with a reduction in body mass index and vitamin D levels, often contributes significantly. Prevention and treatment of fractures in alcohol abusers has received limited attention, and there are surprisingly few therapeutic trials to guide clinical intervention. Abstinence has been shown to improve markers of bone turnover within 2 months. However, compliance with oral therapeutic agents is often poor, and bisphosphonates may be contraindicated in patients with alcoholic liver disease and varices. The emergence of newer therapeutic options may facilitate controlled prospective studies of the role of parenteral agents in providing protection against both primary and secondary osteoporotic fractures among patients with alcohol abuse.