<p>Diabetes mellitus is increasingly recognized for its detrimental impact on skeletal health. This narrative review explores the complex interplay between diabetes and bone fragility, emphasizing differences in pathophysiology, clinical outcomes, and management strategies in type 1 and type 2 diabetes mellitus (T1DM and T2DM). T1DM is associated with reduced bone accrual and lower peak bone mass due to insulin deficiency and chronic hyperglycemia, leading to impaired osteoblast activity and bone matrix quality. In contrast, T2DM presents a paradoxical scenario wherein individuals may have normal or elevated bone mineral density (BMD) but still face increased fracture risk due to impaired bone quality and turnover. Mechanisms such as advanced glycation end-product accumulation, oxidative stress, altered Wnt signaling, and chronic inflammation contribute to compromised bone strength. Standard diagnostic tools like dual-energy X-ray absorptiometry (DEXA) often underestimate fracture risk in diabetics, necessitating advanced imaging modalities like HR-pQCT and the incorporation of trabecular bone score (TBS) for accurate assessment. The review outlines both lifestyle and pharmacologic strategies tailored for diabetic bone disease, including the role of weight-bearing exercise, vitamin D and calcium supplementation, and the efficacy of antiresorptive and anabolic therapies. It also addresses fall risk, medication-related skeletal effects, and management nuances in special populations such as postmenopausal women, children with T1DM, and older adults. Finally, it calls for integrated screening approaches, refined fracture prediction tools, and personalized treatment strategies to mitigate the skeletal burden of diabetes and improve long-term outcomes.</p>