Clinical fractures beyond low BMD

The risk of fractures is multifactorial and is related to the ability of bone to resist fracturing, which depends on its material and structural properties, and on the intensity, frequency and impact of trauma. Low BMD is a major determinant of bone strength and fracture risk. However, most patients with a fracture have no osteoporosis and BMD explains <50% of bone strength and fracture risk. Beyond BMD, bone strength can be calculated by ana lysis of 2D and 3D structural images of the bone, but this is not yet part of daily clinical practice. Fracture risk can be evaluated by integrating BMD with systematic evaluation of clinical risk factors, such as in the fracture risk assessment tool (FRAX) case finding algorithm (age, personal and family history of clinical fractures, life style, diseases and medications). Clinical risk factors, not included in FRAX, are fall risks, the number and timing of previous clinical fractures, the presence, number and severity of morphometric vertebral fractures and the dose of glucocorticoids. These have been included in other case finding tools, such as the Garvan Fracture Risk Calculator, the Fracture Risk in Glucocorticosteroid Users and the Maastricht Fracture Risk Nomogram. Further refinement of case finding algorithms will be needed to integrate BMD, bone strength calculations and clinical risk factors into a single algorithm for fracture risk prediction, that can be used in daily practice.