Background <p>Osteoporotic fractures (OPF) cause pain and trigger physical and mental health problems for patients. However, the underlying mechanism of OPF remains unclear. This study aims to investigate the diagnostic value and inhibitory effect on fracture healing of miR-204 in OPF.</p> Methods <p>A total of&#xa0;104 osteoporosis patients and 119 OPF patients were included from the clinic. The RT-qPCR was performed to detect serum miR-204 level. The ROC curves were plotted based on miR-204 expression. Correlations between miR-204 and clinical factors were analyzed by the chi-square test in the OPF group. Independent risk factors were analyzed by multivariate logistic regression. The effect of miR-204 on fracture healing was explored in vitro experiments on BMSCs cells. The expression of miR-204 and TGF-β1 was assayed by the RT-qPCR in BMSCs transfected with miR-204 mimic NC, mimic, inhibitor NC, and inhibitor. The CCK-8 was applied to detect cell proliferation.</p> Results <p>Serum miR-204 level was significantly increased in the OPF group. The ROC curve confirmed the diagnostic value of miR-204 for OPF. The levels of Ca²⁺, β-CTX, 25(OH)D3, and T-score were correlated with miR-204 expression. The levels of Ca²⁺, miR-204, and T-score were identified as risk factors for OPF. miR-204 overexpression inhibited the proliferation of BMSCs, reduced the expression of osteogenic differentiation factors (ALP and BSP), and decreased the expression of factors (TGF-β1 and BMP) that promote fracture healing.</p> Conclusion <p>Elevating miR-204 promotes OPF development and impairs BMSC-mediated osteogenic differentiation and repair of fractures, warranting further in vivo validation. Inhibition of miR-204 may enhance osteogenic differentiation and fracture healing, representing a potential avenue for future therapeutic investigation in OPF.</p>