Worldwide Fracture Prediction

J Clin Densitom. 2017 Jul-Sep;20(3):397-424. doi: 10.1016/j.jocd.2017.06.008. Epub 2017 Jul 19.


The substantial increase in the burden of non-communicable diseases in general and osteoporosis in particular, necessitates the establishment of efficient and targeted diagnosis and treatment strategies. This chapter reviews and compares different tools for osteoporosis screening and diagnosis; it also provides an overview of different treatment guidelines adopted by countries worldwide. While access to dual-energy X-ray absorptiometry to measure bone mineral density (BMD) is limited in most areas in the world, the introduction of risk calculators that combine risk factors, with or without BMD, have resulted in a paradigm shift in osteoporosis screening and management. To-date, forty eight risk assessment tools that allow risk stratification of patients are available, however only few are externally validated and tested in a population-based setting. These include Osteoporosis Self-Assessment Tool; Osteoporosis Risk Assessment Instrument; Simple Calculated Osteoporosis Risk Estimation; Canadian Association of Radiologists and Osteoporosis Canada calculator; Fracture Risk Assessment Calculator (FRAX); Garvan; and QFracture. These tools vary in the number of risk factors incorporated. We present a detailed analysis of the development, characteristics, validation, performance, advantages and limitations of these tools. The World Health Organization proposes a dual-energy X-ray absorptiometry-BMD T-score ≤ -2.5 as an operational diagnostic threshold for osteoporosis, and many countries have also adopted this cut-off as an intervention threshold in their treatment guidelines. With the introduction of the new fracture assessment calculators, many countries chose to include fracture risk as one of the major criteria to initiate osteoporosis treatment. Of the 52 national guidelines identified in 36 countries, 30 included FRAX derived risk in their intervention threshold and 22 were non-FRAX based. No universal tool or guideline approach will address the needs of all countries worldwide. Osteoporosis screening and management guidelines are best tailored according to the needs and resources of individual counties. While few countries have succeeded in generating valuable epidemiological data on osteoporotic fractures, to validate their risk calculators and base their guidelines, many have yet to find the resources to assess variations and secular trends in fractures, the performance of various calculators, and ultimately adopt the most convenient care pathway algorithms.

Keywords: FRAX; Fracture risk calculator; guidelines; risk factors.

Publication types

  • Review

MeSH terms

  • Absorptiometry, Photon
  • Africa / epidemiology
  • Age Factors
  • Algorithms
  • Asia / epidemiology
  • Bone Density
  • Cancellous Bone / diagnostic imaging
  • Europe / epidemiology
  • Global Health
  • Hip Fractures / epidemiology
  • Hip Fractures / etiology
  • Humans
  • Incidence
  • Latin America / epidemiology
  • North America / epidemiology
  • Osteoporosis / complications*
  • Osteoporosis / diagnosis*
  • Osteoporosis / diagnostic imaging
  • Osteoporotic Fractures / epidemiology*
  • Osteoporotic Fractures / ethnology
  • Osteoporotic Fractures / etiology*
  • Practice Guidelines as Topic
  • Risk Assessment / methods
  • Risk Factors
  • Surveys and Questionnaires*
  • Validation Studies as Topic