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Although type 2 diabetes mellitus (T2DM) patients have normal or even elevated bone mineral density, they still face increased risk for fracture, a phenomenon known as the "Diabetes-bone mineral density paradox". This paper summarizes current domestic and international evidences regarding changes in bone mineral density, fracture risk, and the potential underlying mechanisms in patients with T2DM. Existing studies indicate that bone mineral density changes in T2DM patients are heterogeneous. In contrast, evidence for an increased fracture risk is relatively consistent, especially for hip fractures. Potential mechanisms might involve enhanced bone formation associated with hyperinsulinemia, as well as the combined effects of advanced glycation end products accumulation, low bone turnover, microarchitectural deterioration, and impaired bone quality. The "diabetes-bone mineral density paradox" suggests that the assessment of diabetes-related bone fragility should not rely solely on bone mineral density, but also consider bone quality and bone microstructure parameters. Multidimensional prospective studies are needed in the future to further improve fracture risk assessment for patients with T2DM.