Dual-energy X-ray absorptiometry (DXA) is generally a very useful tool for assessing bone mineral density (BMD) and fracture risk. However, observational studies have shown that in certain instances, BMD as measured by DXA systematically over- or underestimates fracture risk. We herein describe the clinical conundrums encountered when assessing fracture risk by DXA in patients with primary hyperparathyroidism or type 2 diabetes and those of Chinese ethnicity. Furthermore, we discuss how advanced imaging technology that examines skeletal microarchitecture is furthering our understanding of fracture risk in these clinical situations.
Abbreviations: BMD = bone mineral density BMI = body mass index BMS = bone material strength BMT = bone microindentation testing 3D = 3-dimensional DM2 = type 2 diabetes mellitus DXA = dual-energy X-ray absorptiometry μFEA = microstructural finite element analysis FRAX = fracture risk assessment tool HRpQCT = high-resolution peripheral quantitative computed tomography ID = indentation distance IDI = indentation distance increase ITS = individual trabecular segmentation PHPT = primary hyperparathyroidism PTH = parathyroid hormone TBS = trabecular bone score.