This study examined the association between circumstances of occupational same-level falls and the risk of wrist, ankle and hip fracture in women over 45 years of age. Cases of fractures and matched controls who suffered non-fracture injuries, all from same-level falls, were selected from workers' compensation claims data. Cases and controls were matched on age, season of fall, industry and state. Information was obtained about manual material handling, fall hazard, initiating event and fall location. Falls during pushing/pulling were associated with increased wrist fracture risk. Falls due to tripping were associated with increased wrist fracture risk, but decreased risk of ankle fracture. Falling outdoors was associated with increased wrist and ankle fracture risk. Increasing age was associated with increased injury risk from tripping-initiated vs. slipping-initiated falls. Few circumstances increased risk of fracture at multiple sites, indicating that they affect risk of fracture by primarily affecting point of impact. The proportion of female workers over 45 years of age, who are at increased risk of fracture, is increasing in developed countries. This study examined the associations between circumstances of falls and wrist, ankle and hip fracture risks among these workers and found that the associations differed by fracture sites.