Thalassaemic bone disease is a composite entity in which structural damage to bone is brought about by several influences, each of which may affect the bone in a different way and to a variable degree, but which may co-exist in individual patients. Understanding these damaging factors in each patient should lead to an orthologistic approach to management. However there is currently no agreed investigational protocol for the elucidation of these factors and no evidence based protocol for management. In this article the role of each of the causative influences is reviewed according to current literature and a critical examination of investigation and management is made. The conclusion is that there is a lack of agreed guidelines for the investigation and monitoring of thalassaemia patients and a lack of evidence based protocol for management of patients whose bone disease starts at an early age and continues for the rest of their lives. The natural history of this complex osteopathy and the long term effects of therapy are not well documented.