Longevity in African populations is increasing, where deprivation and malnutrition are common; hence fragility fracture incidence is expected to increase. Healthcare systems must adapt to provide for this aging population; however, currently fragility fracture incidence has yet to be determined in any West African setting. This study aimed to determine age- and sex-specific hip fracture incidence rates in adults in The Gambia, compare these with rates from other Southern African countries, and estimate future national hip fracture projections. All hip fracture cases in adults aged ≥40 yr, presenting to a hospital or traditional bone setter (TBS) in the study area over 2-yr, were identified. Age- and sex-specific hip fracture incidence per 100 000 person-years were estimated using the 2024 Gambian Population census. Incidence rate estimates were compared between The Gambia, Zimbabwe, South Africa, and Botswana. In The Gambia, future hip fracture numbers were estimated through to 2054 using United Nations population projections. Over 2-yr, 226 hip fracture patients, mean (standard deviation [SD]) age 71.2(12.5) years, 64.6% female, presented to hospital (184[81.4%]) or TBS (42[18.6%]). Most presented with a fragility fracture (205[90.7%]). High-impact trauma (eg, traffic accidents) was more common in younger men. Delays in presentation were common (68[30.1%]). Incidence rates for adults ≥40 yr in The Gambia were 28.1 and 51.7 per 100 000 person years for men and women, respectively, increasing with age. In those age ≥ 80 yr, incidence rates plateaued in men. The number of hip fractures is estimated to increase from 166 in 2024 to 621 by 2054. Age-specific hip fracture incidence rates were broadly comparable between The Gambia, Zimbabwe, Botswana, and Black South Africans. In summary, fragility fractures in Gambian adults were common, indicative of age-associated osteoporosis. Hip fracture cases will almost quadruple over coming decades; therefore, health service capacity must expand to manage this rising demand.